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11090045 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22647 ROYAL OAK WAY CONTRACTOR:DRAEGER PERMIT NO: 11090045 CONSTRUCTION INC OWNER'S NAME: LACEY ROBERT E AND LINDA M TRUSTEE 605 COMMERCIAL ST DATE ISSUED:09/13/2011 NER'S PHONE: SAN JOSE,CA 95112 PHONE NO:(408)536-0420 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT PLUMB License Class C � Lic.# 1,1'1 7,6 � MECH RESIDENTIAL� COMMERCIAL � ContractorQI,UCI r L�1 NC I. Date 1// -3 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SFDWL REROOF,12 SQ,TEAR OFF SHAKE ROOK, INSTALL (commencing with Section 7000)of Division 3 of the Business&Professions 1/2"CDX RADIANT BARRIER,INSTALL PRESIDENTIAL TL Code and that my license is in full force and effect. ASPHALT SHINGLES. INSTALL SHINGLE VENT(RIDGE 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:$9400 permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:34232032.00 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 DA S FROM LAST CALLED INSPECTION. 9.18. ' P Date: Date Issued b /�'' Signature � - y: 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 I,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) I,as owner of the property,am exclusively contractingwith licensed contractors to Signature f plicant: Date: 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 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 I 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 505,25533,and 25534. become subject to the Worker's Compensation provisions of the Labor Code,I must Ow r r aut zed t: �f forthwith comply with such provisions or this permit shall be deemed revoked. -5ate: 1 APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is Ig I hereby affirm that there is a construction lending agency for the performance of Hork's correct.I agree to comply with all city and county ordinances and state laws relati 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 it' ^nify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the Lender's Address g,-ging 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 CITY OF CUPERTINO 3 ITEMS OF 54 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 34232032. 00 DATE ISSUED. . . . . . . : 09/13/2011 RECEIPT #. . . . . . . . . BS000014752 REFERENCE ID # . . . : 11090045 SITE ADDRESS 22647 ROYAL OAK WAY SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER LACEY ROBERT E AND LINDA M TRU ADDRESS 22647 ROYAL OAK WAY CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-5618 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 9,400 . 00 1. 00 0 . 00 1 . 00 0. 00 1BSEISMICR VALUATION 9,400 .00 0. 94 0. 00 0 .94 0. 00 1REROOFRES SQ FEET 12 . 00 168 . 00 0 . 00 168. 00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 169. 94 0. 00 169 .94 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•building(c�cupertino.org CUPERTI 0 PROJECT ADDRESS 71[�[ j APN 3 y 3 3 C �3-- OWNER NAME �yf rG�, -- (J� E MAII CITY, STATE ZIP n� FAX STREET ADDRESS ��^� r J,� )/io CA I APPLICANT NAME `f �l PHONE E-MAIL 5 200 - UC STREET ADDRESS ' CITY,STATE ZTPnM� F 3b141-5 N1 rGCc Jvv[` ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR N LICENSE NUMBER L./ 1® LICENSE TYPE/ BUS.LIC. COMPANY NAME E-MAIL �j( l G- FAX - STREET ADDRESS CrI'y,STAT� US q5l]Z— PHO �yi ARCHITECT/FNGIIdEER NAME LICENSE NUMBER ` BUS.LIC.' CONQANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or Duplex ❑ Multi-Family ROOF) `��XT'AREA: VALUATION: STRUCTURE: El Commercial 1 7,C , il 0 400 �� EXISTING ROOF TYPE: ❑BUU-T-UP ROOF ❑ASPHALT SHINGLES >400D SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY) REMOVE/REPLACEAZYES IF NO, PLYWOOD 'h" ❑ PLYWD ❑ OSB PTTCH: ROOF ❑NO LAYERS. THICKNESS: ❑ 5/8" TYPE: CDX —4 :12 CLASS: A ICC-ES REPORT'S PROPOSED ROOF TYPE: 13BUILT-UPROOF AASPHALT SHINGLES ❑WOOD SHAKES ElWOOD SHINGLES r ❑OTHER DESCRIPTION OF WORK ICECOX 0e4d1Urt_(_ �r us l d l eL ��- L he-S. &&// ilk �/ 11a�S �/e [A�A (6L o� 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 building construction. I au rize r ntatives of Cupertino to enter the above-identified property for inspection purposes. qlzll Signature of Applicant/Agent Date: jai - — — SUPPLEMENTAL INFORMATION REQUIRED If building is associated with a Home Owner's Association,provide letter ""}' 1 V.- '= ft of approval from HOA. _ _ - -- Tri_ =_ >y Provide Planning approval to verify if there any restrictions. $ Q m = --�:_• --- _'?°. -»�..Iraar=rr�-N��i>�.'yA- EM Provide copy of Manufacturer's Installation Specifications. '".Sam Provide signed copy of Cupertino's Tear-Off Policy. a�—L—,tet-___ ._.. ReroofApp_2011.doc revised 03/02111