11090048 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22667 ROYAL OAK WAY CONTRACTOR:DRAEGER PERMIT NO: 11090048
CONSTRUCTION INC
OWNER'S NAME: LUIZ PEREGRINO TRUSTEE 605 COMMERCIAL ST DATE ISSUED:09/13/2011
"ER'S PHONE: SAN JOSE,CA 95112 PHONE NO:(408)536-0420
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
� 1
License Class _ Lic.# ��� �/
p� n � j/� MECH RESIDENTIAL COMMERCIAL �
Contractor//fLisejg( C �'�"//'PSL' Da el
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:SFDWL REROOF,12 SQ,TEAR OFF SHAKE ROOK,
(commencing with Section 7000)of Division 3 of the Business&Professions INSTALL
Code and that m license is in full force and effect. 1/2"CDX RADIANT BARRIER,INSTALL PRESIDENTIAL TL
Y 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:34232030.00 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 t Cupertino Municipal Code,Section 180 D S FROM T CALLED INSPECTION.
9.18.
Signatur Date ! Z� Issued by: Date:
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) n Date:
�V"
I,as owner of the property,am exclusively contracting with licensed contractors to Signature o A,pplicar►t
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. 1 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 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. Own r or au ize n .
Date:
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 Hork'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
'emnify 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
r,,anting 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
(408)777-3228• FAX(408)777-3333 •building(cDcupertinc.org \
CUPERTINO
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PROJECT ADDRESS APN: C 60
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owNER NAJ.� � PsoNEVI��` ,
CITY, STATE,ZIP^ /�'n o />i{ �, FAX
STREET ADDRESS �` FILr til
of Cit
APPLICANT NAME v �/l PHONE I E-MAIL, cA�2c� / fr zb►3 U�
CIIY,STATE,ZIPn � I F 36 �•' 1��
STREET ADDRESS I G� J
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR CDNTRACTDR AGENT ❑ ARCHITECT El ENGINEER ❑ DEVELOPER El TENANT
CON RACTOR N LICENSE NUMBER L.1� I LICENSE TYPE BUS.LIC.#z
COMPANYNAME 01
E-MAII (/( FAX
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STREET ADDRESS CITY,STAT US asl I Z- PHO �yj j
AR�CT/ENGINEER NAME LICENSE NUMBER BUS.LIC (�[
COMPANY NAME E-MAILFAX
STREET ADDRESS CITY,STATE,ZIP PHONE
SFD or Duplex E] Multi-FamilyROOF AREA:�J r/ VALUATION:
�
USE OF
STRUCTURE: ❑ Commercial V
EXISTING ROOF TYPE: 11BUILT-UPROOF ❑ASPHALT SHINGLES FOOD SHAKES 11 WOOD SHINGLES El OTHER(SPECIFY)
LACEKY�-
REMOVF/nRk.EPNO• ��aCK�NES&
'h" ❑ _ PLYWD OSBPITCH ROOF❑ LAYERS: ❑ 5/8" TYPE: CDX —+—'12 CLASS: A
ICC-ES REPORT#
PROPOSED ROOF TYPE: ❑BumT-UP R00F AASPHALT SHINGLES 11WOOD SHAM 13WOOD SHINGLES ElOTHER
DESCRIPTION OF WORK rt
r rQ �s a1Proide eL D_ AspivaLl 5blvvite-Ste
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 tc enter the above-identifiedproperty for inspection purposes.
Signature of Applicant(Agent Date:
SUPPLEMENTAL INFORMATION REQUIRED
_If building is associated with a Home owner's Association,provide letter
of approval from HOA. ' _
Provide Planning approval to verify if there any restrictions. .
_ - _-
Installation Specifications.
Provide copy of Manufactlu�er's Ins =� �3.�.-=`�`_�T"
Provide signed copy of Cupertino's Tear-Off Policy.
Reroof4pp_201 Ldoc revised 03/02/11