12100146 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10578 WRITE PIR CT CONI'RACfOR:FOUR SEASONS ROOFING PERMIT NO: 12100146
OWNER'S NAME: CHO SUHO AND JAW YOUNGSUK PO 110\ 16611 DA'Z'E ISSUED: 10119/2012
OWNER'S PHONE: 4082523100 SAN.IOSE.CA 95109 PHONE NO:(408)278-0330
❑ / LICENSED COMRACfOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT —1 PLUMB--
License Class3,F Lie.q
M
� � •• ECFI r RESIDENTIAL(..J COMMERCIAL(J
ContractoryY�/,Ut —Date IVIIJZzZ
1 hereby aRinm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: Rr-ROOF,REMOVE SHAKE&INSTALL PLYWOOD AND
(commencing with Section 7000)of Division 3 of the Business&Professions COMP
Code and that my license is in full force and effect. SHINGLES 13 SQ CLASS A
hereby affirm under penalty of perjury one of the Following two declarations:
I have and will maintain a cenificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of die work for which this
permit is issued. Sq.Ft Fluor Area: Valuation:$18000
APPLICANT CER'I'll'ICA'1'ION
I certify that I have read this application and state that the above information is ,U;N Number:35905121.00 Occupaney'rype:
cored.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accme against said City in consequence of the
granting of this permit. Additionally,the applicant undersmtdsand will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non nt source regulations per the Cupertino Municipal Code,Sectiat 180 DAY7fJOM LAST CALLED INSPECTION.
9.18.
Signaut Date Issued y: G Date:
�l)
❑ OWNER-111)1 LDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Law for one of Rf:ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material beim;installed If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, installed w'ithor first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, Enacg�ilre
on. _
Business&Professions Code) /Q�
I,as owner of the property',am exclusively contracting with licensed contractors to o Ap titan Date: f o
construct the project(See.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three At,[,ROOF COVERINGS TO Illi CLASS"A"OR BETITR
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's 11A7,ARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
1 have and will maintain Worker's Compensation Insurance,as provided for by California Ilealth&Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code.Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,.should I use equipment or devices which emit hvardou.s air
I certify that in the performance of the work forwhich this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
Compensation Imus of California. If,after making this cenificate of exemption,I Ilealth&Safety Code,Sections 25505,25533.and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. err or: th izr g
Irate•
,U'PLICAN'I'CE R'I'IFICA'I'ION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city arra county ordinances and state laws relating I hereby aBimm that there is a construction lending agency for the performance of mark's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Leader's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECI"S DECLARATION
9.18.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional
lZ ( vvl � LP
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
j' ADDRESS: ��7 �J y DATE: 10/18/2012 REVIEWED BY: jsg
APN: BPh!: 'VALUATION: $4,500
*PERA1ITTYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY SFD or Duplex PENTAINATION 1SFDWLR00F
USE: PERMIT TYPE:
WORK Reroof, remove shake instal plywood and comp shingles
SCOPE
FEEID ROOFAREA
s.fJ
1REROOFFRES 1,300
r :
Much. Ilan Check Plumb. Plun Check Flee.Plan Check
Mech. Permit Fee: Plumb. Per mir Fee: Elec. Permit Fee:
Other,tkch. Insp. Odrrr Plumb Ince. Other Elect Insp.
.Neth.Insp.Fee: Plumb. Lisp. Fee: Elce.Lisp.Fre:
A'OTE:.This estimate does not include fear due to other Departments(i.e. Planning, Public Works, Fire,SanitaryServer District,School
District,etc). These fees are based on the prelitninan information mailable and are only an eminate Contact the Dept for addn'l in e.
FEE ITEMS (Fee Resolution 11-053 F_2 7/1/122 FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Suppl. PC Fee
Phmrb./A/ech./Elec
Permit Fee: $195.00
Suppl. Insp Fee
Phanb.Gllech./Elec
Ph nth.lHech.lEtee Permit Fee:
Coiirnvction Tax:
Administrative Fee:
Work Without Permit? O Yes Q No $0.00
Advanced Plartrting Fees:
Travel Documentation Fees:
i
Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTILS:, $196.50 $0.00 r TOTALFEE:;• $196.50
Revised: 10/01/2012
( z i 0C) a�
RERO®FPERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO.CA 95014.3255 IN X�l
(408)777-3228- FAX(408)777-3333'guild-, OS JcupeflinD.OER
GVPERTINO
PROIECi.'SAD "F"
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PHONER-MAIL
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CONTACT NAMR PHO?; Oe.MAIL
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STRFL:n,.00RL•SS - CITY.5MT•c..711P FAX
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❑QW,1FR G DWNeR-nuu.DGR ❑ OwNFRAGE1,T JeCONTRAC-IOR GCONTRACTOR+GENT 11 ARCHITECT 11ENGINPER ❑ DEVELOPER ❑ TENA1
CONTRACTOR NAMEFLICF-NSENUNISER LR'f:NSET fE I BUS.LICA
COMPANY\AMG E-M.1:L FAA
STR=Er ADDRESS CITY.STATZ.7.IP
S�2 I a os G PHONE - '
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ARCHITECYN01NEf.R NAMF- LICENSE NLLIBER BV9.LIC.n
COMPANY NAME E-MAIL. FAX
STREET ADDRESS I CITY,STATE.Z II' y PHONE.
USE OF ❑ SFD or Duplex ji Muiti-FamilynWF AREA: je VALUATION: p� -
STRUCTURE: ❑ CommcmiRl S6i_ �P
,i
EXIS ❑
r1YORODFTYPF; ❑RVILT-UPRCOF A<PIInyT 5111SC.Ll.G y+�Y WOODSHARF3 ❑wOODSHINGLES ❑OTHaR ISPECIFY)
REMOVEMEPLACE YFSI 'FNO. pLY\V OD ldp; ❑ PLYtYO Edl OSD PrtCH. RWP
❑ N '4;z
FRS, T411C _9-3a, Tl' _1FSA_ 12 CI nS A
PROPOSED ROOF TYPE: ❑BUILT• PR [CC-FS RRPORT0
U OOF �ASPHILLTSPIINOLES ❑tfVOU 516aKE5 ❑\VOOD SHIAOLE$ f�UTHF.R
DESCRIPTION OF WORN:
W.00c�— v
-
I nS�a1 ��21 " CDx
.Aa J1-4-"-aeel v4-6
ee �Q[es i.dGn '_�t conhLes�C�als,� Ccs,a�ol—C"By my my signature below.I certify to each of the following: I am the property owner or mdhonmd agent to act on the property ovmcr'5 Millf. I have mod the
application and the inramunion I have provided is correct. 1 have rend the DRscripuon of Work nod verity It is accurnte, I Rgme to comply with all applicable local
ordinances and swtc laws Tclating to building cons tion. I o orizc r<pres ' tiv •of Cupertino to<nter tha above•Idclnifcd popery fof inspection purpos<s.
SignaWmof AppI!=ru/Agent: _ .= Dmc,
SUPPLEMENTAL INFORMATION REQUIRED OFFICE.USE ONLY
I f building is associated with B Home Owner's Association.provide letter PLAN CHECK TYPE RounNc SW
orapproval from HOA. Cl OY¢R•THPCOU=R ❑ BUILDINDPLANFAINuo'
Provide Planning approval to verify ifthe a any restrictions. [1 EXPRESS ❑ PL\A'NING PIRA"RC\'IGW
Provide copy of Mnnufn<Tumr's.Installation Spe<ifid,tione. RrANnARU 0 mnnnn>r
Provide signed copy of Cupertino's Tcar•Off Policy. ❑ OTHER:
RerooJlpp_20l i.doc revised 03/l6/U