12120087 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10480 ANN ARBOR AVE CONTRACTOR:C&C ROOFING PERMIT NO: 12120087
OWNER'S NAME: SAUL CHAIKIN 89 S 21 ST DATE ISSUED: 12/17/2012
OWNER'S PHONE: 4082550722 SAN JOSE,CA 95116 PHONE NO:(408)298-1868
❑ LICENSED CONTRACTOR'S DECLARATIONF
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# Zq - F f—
MECH RESIDENTIAL COMMERCIAL
Contractor C 1j-6 a,C , t Date /L - ;2- -/
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE SHAKE ROOF OF GARAGE INSTALL 1/2 CDX
(commencing with Section 7000)of Division 3 of the Business&Professions REROOF
Code and that my license is in full force and effect. 50 YEAR COMP 9 SQFT CLASS A
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate 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.
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$6400
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is APN Number:32628019.00 Occupancy Type:
correct.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 accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature ��t��O�i���s�..—Date12 -/ - Z Issued b _ Date;/Z_— 7
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1,as owner of the property,or my employees with wages as their sole compensation, installed without 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, inspection.
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: � ,��� � _y. Date: /�-/ -`�
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS 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
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this
Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
1 certify that in the performance of the work for which 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 laws of California. If,after making this certificate of exemption,I health&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. Ower or authorized a nt:
-� Date:_LL�1 Z
APPLICANT CERTIFICATION 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 and county ordinances and state laws relating I hereby affirm that there is a construction lending agency for the performance of wrk'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 Lender'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 the 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 ARCHITECT'S DECLARATION
9.18.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPER`t`INO (408)777-3228• FAX(408)777-3333•build ingecupertino.orcl
PROJECT ADDRESSAPN# �L J
/0'/- 90 h♦^ ,-^
OWNER NAME PHONE E-MAIL
STREET ADDRESS CITY, STATE,ZIP FAX
CONTACT NAME C PHONE E-MAIL
STREET ADDRESS CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ® CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME L'� 2'/C LICENSE NUMBER l/S 1` G LICENSE TYPE BUS.LIC.#
COMPANY NAME E-MAIL
G' 6 G'- /'O(►;,c/lu
STREET ADDRESS CITY,STATE,ZIP . r , PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF P'SFD or Duplex ❑ Multi-Family ROOF AREA: VALUATION:
STRUCTURE: ❑ Commercial
r
EXISTING ROOF TYPE: ❑BUILT-UP ROOF ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY)
REMOVE/REPLACE YES IF NO, PLYWOOD A" ❑ PLYWD ❑ OSB PITCH: 7 ROOF
NO #LAYERS, THICKNESS: 135/8" TYPE: CDX '12 CLASS: A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF HI T SHINGLES ❑WOOD SHAKES C1WOOD SHINGLES 11OTHER ICC-ES REPORT#
A
DESCRIPTION OF WORK:
Ear a a' r e4 �
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to build/in;construction. I authorize repr/eseatatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: /����G���f L _G_ .L�. Date: 12
SUPPLEMENTAL INFORMATION REQUIRED otcE USE ONLY
_If building is associated with a Home Owners Association,provide letter P»CIIE�Tlw- '°° xouitx SUP
of�f approval from HOA. �TI1W-COUNTER l�D*d PIAN REVIEW
•'Provide Planning approval to verify if there any restrictions. [] ExrREss, L7 PI AHTNINGPLANREVIEW
IZ-60-vide copy of Manufacturer's Installation Specifications. .STAND RD: D FIRE DEPT, ,
r"Provide signed copy of Cupertino's Tear-Off Policy. OTR
ReroofApp_2011.doc revised 03/16/11
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 10480 ann arbor ave. DATE: 12/17/2012 REVIEWED BY: bobs.
APN: BP#: *VALUATION: 1$6,400
q*PERMITTVPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 SFDWLROOF
USE: p PERMIT TYPE:
WORK
SCOPE
Ot '—Aii' Ll
11<,i
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS: p .c? ,,,n, ,¢2 s PERMIT# 00
OWNER'S NAME: L, v PHONE# ? cr9
GENERAL CONT TOR: G �� r BUSINESS LICENSE#
ADDRESS: T CITY/ZIPCODE:�u � e'` '
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: rl! ��--/
z 2
Signature Date
Please check applicable subcontractors and complete the following information:
&/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
Glass /Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
1`2
Owner/Contractor Signature Date