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11090156 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10454 SCENIC CT CONTRACTOR:EXECUTIVE ROOFING PERMIT NO: 11090156 OWNER'S NAME: LINDA N SHUM TRUST 313 INGRAM CT DATE ISSUED:09/21/2011 OWNER'S PHONE: 4082556737 SAN JOSE,CA 95139 PHONE NO:(408)458-6044 / LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB� License Class C Lic.# � MECH f— RESIDENTIAL COMMERCIAL Contractor 1� Date _1 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RE-ROOF REMOVE&REPLACE COMP SHINGLES CLASS A 35SQ (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 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 Sq.Ft Floor Area: Valuation:$15500 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:35707018.00 Occupancy Type: APPLICANT CERTIFICATION 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 PERMIT EXPIRES IF WORK IS NOT STARTED upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally,the applicant understands and will comply with all non-point sou a regulations per the Cupertino Municipal Code,Section 9.18. Issued by:/ Date: 4 Signature Date ,2 rt f✓ OWNER-BUILDER DECLARATION RE-ROOFS: All roofs shall be inspected prior to y roofing material being installed.If a roof is i aereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an i spection,I agree to remove all new materials for the following two reasons: inspection. 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date: q �1' Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 1 certify that in the performance of the work for which this permit is issued,I shall Health&Safety C de,Sections 25505,25533,and 25534. not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I Owner or orr d ag nt: Zr become subject to the Worker's Compensation provisions of the Labor Code,I must _Date: ll forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.) correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION ,,ting of this perm. Additionally,the applicant understands and will comply _i all non-point so a regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records. 9.18. Z Date Licensed Professional Signature CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35707018 . 00 DATE ISSUED. . . . . . . : 09/21/2011 RECEIPT #. . . . . . . . . BS000014822 REFERENCE ID # . . . : 11090156 SITE ADDRESS 10454 SCENIC CT SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER LINDA N SHUM TRUST ADDRESS 10454 SCENIC CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : DAVID A BERKE CONTRACTOR . . . . . . . : DAVID BERKE LIC # 26871 COMPANY . . . . . . . . . . : EXECUTIVE ROOFING ADDRESS . . . . . . . . . . : 313 INGRAM CT CITY/STATE/ZIP . . . : SAN JOSE, CA 95139 TELEPHONE . . . . . . . . : (408) 458-6044 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 15, 500 . 00 1. 00 0. 00 1 .00 0. 00 1BSEISMICR VALUATION 15, 500. 00 1.55 0 . 00 1.55 0 .00 1REROOFRES SQ FEET 35 .00 490. 00 0. 00 490 .00 0. 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 492 . 55 0. 00 492 .55 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 492 .55 AMEX --------------- TOTAL RECEIPT 492 .55 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 n i CUPERTINC3 (408)777-3228• FAX(408)777-3333 • building aecupertino.org r0 t�1 tri PROSECT ADDRESS �.1 IMC' `w J ��kAPN# OWNER NAME 1 )904 V1AA C �I�' �� EMAII GNeq S�vw• P��1r�oC'o STREET ADDRESS10% � t� C CITY, STATE,ZIP /-y�' FAX APPLICANT NAME (� PHONE E-MAIL STREET ADDRESS I„ d_/* �1 CITY,STATE, ZIP fS7 FAX lift-❑OWNER EI OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT,,(❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME CJTtYL LICENSE NUMBER LICENSE TYPE BUS.LIC.# COMPANY NAME ko ( E-MAIL j�/ FAX 1f�6ylla STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER ,L BUS.LIC.# (� COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF �SFD or Duplex ❑ Multi-Family ROOF mAREA� � VALUATION:: I � �� ' STRUCTURE: ❑ Commercial 3C //►► EXISTING ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES 13WOOD SHINGLES THER(SPECIFY) v'IWZtApL! REMOVE/REPLACE YES IF NO. PLYWOOD ,e ❑ PLYWD /_q OSB PITCH: L ROOF NO #LA THICKNESS: ❑ 5/8" TYPE: ❑ CDX 12 CLASS: A PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT# DESCRIPTION OF WORK � . 51"_,tolM I7;we W, 056 w m_ lu By my signature below,I certify to each of 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 hay=ovi d 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 buil construction. I authorize.representatives of Cupertino tc enter the above-identified prope L;for inspection purposes. Signature of Applicant/Agent A Date: SUPPLEME ORMATION REQUIRED If building is associated with a Home Owner's Association,provide letter � T�'?F ;�� __ocll'ny1;i - of approval from HOA. - � : _Provide Planning approval to verify if there any restrictions. Provide copy of Manufacturer's Installation Specifications. , � ~=. rovide signed copy of Cupertino's Tear-Off Policy. ,_ A �— — ReroofApp_2011.doc revised 03/02/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10454 scenic ct. DATE: 09/21/2011 REVIEWED BY: bobs. APN: BP#: 'VALUATION: 1$15,500 PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof PRIMARY SFD or Duplex PENTAMATION 1SFDWLROOF USE: _T_ PERMIT TYPE: WORK remove and replace comp shingles. SCOPE FEE ID ROOF AREA s.f. 1 REROOFFRES 3,500 T7 I T I T F-71; 71 Li Li L1 NOTE: This estimate does not include fees due to other Depts(i.e.Public Works,Sanitary Sewer District,School District,etc.). Thesefees are based on the preliminary in ormation available and are only an estimate. Contact the De t or addn'1 info, FEE ITEMS (Fee Resohition 11-053 Ejf. 7"1-'11) FEE QTY/FEE MISC ITEMS Permit Fee: $490.00 Work Without Permit? Q Yes Q No $0.00 i Strom.Motion Fee: IBSEISMICR $1.55 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $492.55 $0.00 TOTAL FEE: 1 $492.55 Revised: 09/02/2011 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: 1,04CC-N1 C- C-17 PERMIT# OWNER'S NAME: b QdA Ovwx PHONE# GENERAL CONTRACTOR: C3� 1.+o1'tv�i: BUSINESS LICENSE# F7d ADDRESS: 30 I CITY/ZIPCODE: *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 SUBCONT CTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: �+ l e gnature Date Please check applicable subcontractors and omplete 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 S fw Septic Tank Sheet Metal Sheet Rock Tile Date j ner/Contractor Signature