11090040 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10126 ENGLISH OAK WAY CONTRACTOR:DRAEGER PERMIT NO: 11090040
CONSTRUCTION INC
OWNER'S NAME: PETERSON JEAN R TRUSTEE 605 COMMERCIAL ST DATE ISSUED:09/13/2011
PER'S PHONE: SAN JOSE,CA 95112 PHONE NO:(408)536-0420
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG I— ELECT PLUMB r
License Class G. Lic.# (� L./�,� �
Class
q MECH r RESIDENTIAL COMMERCIAL
Contractor a-al W�S�• Date ��
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SFDWL REROOF,11.6 SQ,TEAR OFF SHAKE ROOK,
(commencing with Section 7000)of Division 3 of the Business&Professions INSTALL 1/2"CTX RADIANT BARRIER,INSTALL
Code and that my license is in full force and effect. PRESIDENTIAL TL ASPHALT SHINGLES. INSTALL SHINGLE
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.
I 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 Sq.Ft Floor Area: Valuation:$9000
permit is issued.
APPLICANT CERTIFICATION APN Number:34232144.00 Occupancy Type:
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
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 D YS FRO ST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: 'v� Date:
Signature Date
i
L, OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature 4A plicant: AL5Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by 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.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined b the Ba Area Air
y y Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Oau ord nt:
ize
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
unify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
and expenses which may accrue against said City in consequence of the
g,»+sting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 54 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 34232144 . 00
DATE ISSUED. . . . . . . : 09/13/2011
RECEIPT #. . . . . . . . . : BS000014752
REFERENCE ID # . . . : 11090040
SITE ADDRESS . . . . . : 10126 ENGLISH OAK WAY
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : PETERSON JEAN R TRUSTEE
ADDRESS . . . . . . . . . . : 10126 ENGLISH OAK WAY
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : DRAEGER CONSTRUCTIO
CONTRACTOR . . . . . . . : DRAEGER, JOHN EDWARD LIC # 21895
COMPANY . . . . . . . . . . : DRAEGER CONSTRUCTION INC
ADDRESS . . . . . . . . . . : 605 COMMERCIAL ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408) 536-0420
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 9, 000 . 00 1. 00 0. 00 1 .00 0. 00
1BSEISMICR VALUATION 9, 000. 00 0 . 90 0. 00 0 . 90 0. 00
1REROOFRES SQ FEET 12 . 00 168 . 00 0. 00 168 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 169. 90 0. 00 169 . 90 0 . 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
309 EXTERIOR LATH 311 SCRATCH COAT
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
REROOF PERMIT APPLICATION -
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
(408)777-3228- FAX(408)777-3333 -buildingocupertino.org O
CUPERTINO
PROJECT ADDRESS g J X71{ " APN ` / 3 /t44
OWNER NAME 7 V SLA a V 3 1•`- �j 1� PHONEql E-MAIL
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STREET ADDRESS CII-Y,(� STATE,ZIP FAX t Lv1 Pr10 CA I
APPLICANT NAME w PHONE EMAIL e (FNM
STREET ADDRESS GTI Y.STATE,ZIP��/1 Axse_ ! F ?6r
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR CONTRACTOR AGENT ❑ ARcHr ECT ❑Et4m*---R ❑ DEVELOPER ❑7fr1TENANT,
CONTRACTOR N LICENSE NUMBERm-/ '5 LICENSE TYPl�j BUS.LIC.#Z
COMPANY NAME Q� ! EMAIL j FAX
STREET ADDRESS - CITY,STA US aSI I[�� PHO V lGV
GO-
ARCHITECT/ENGII�ER NAME LICENSE NUMBER BUS.BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CT-Y,STATE,ZIP PHONE
USE OF SFD or Duplex ❑ Multi-Family ROOF AREA: [� � VALUATION:
STRUCTURE: ❑ Commercial 1 1 1 0 t, ' \i u B
EXISTING ROOF TYPE: ❑BUTLT-UP ROOF ❑ASPHALT SHINGLES ROOD SHAKES ❑WOOD SHINGLES ❑OTHER(sPECIFY)
REMOVE/KEPLACEXYES IF NO. PLYWOOD 'h" ❑ PLYWD ❑ OSB PITCi ROOF
❑NO #LAYERS: THICKNESS: ❑ 5/g" TYPE: CDX 12 CLASS, A
PROPOSED ROOF TYPE: ❑B=-UP ROOF AASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT#
DESCRIPTION OF WORK i/
ti J F 04-A (61 F-
By my signature below,I certify to each of the following: 1 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. 1 agree to comply with all applicable local
ordinances and state laws relating to building construction. I a nze r ntat ves of Cupertino to enter the above-identified property for inspection purposes.
Signature ofApplicant/Agent Date:_ r
SUPPLEMENTAL INFORMATION REQUIRED -
If building is associated with a Home Owner's Association,provide letter
of royal from HOA. - tom_
approval �B�_ v.�c•:n�7iE�i>a4V"��-
-Provide Planning approval to verify if there any restrictions.
_Provide copy of Manufacturer's Installation Specifications.
Provide signed copy of Cu ertino's Tear-Off Policy.
ReroofApp_2011.doc revised 03/02/11