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11050210CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10082 AMADOR OAK CT CONTRACTOR: DRAEGER PERMIT NO: 11050210 CONSTRUCTION INC OWNER'S NAME: SHAIN VADIM AND KARINA 605 COMMERCIAL ST DATE ISSUED: 08/22/2011 OWNER'S PHONE: SAN JOSE, CA 95112 PHONE NO: (408)536-0420 ❑ LICENSED CONTRACTOR'S DECLARATION F— F— /, �i License Class �' — / Lic. # , if BUILDING PERMIT INFO: BLDG ELECT PLUMB MECH RESIDENTIAL COMMERCIAL Contractor, i Date 1 hereby affirm that 1 m licensed under the provisions of Chapter 9 JOB DESCRIPTION: REROOF, 9.5 SQUARES, SINGLE PLY TPO OVERLAY WITH (commencing with Section 7000) of Division 3 of the Business & Professions LAYER FR -210 BARRIER Code and that my license is in full force and effect. 1 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 Sq. Ft Floor Area: Valuation: $375 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 APN Number: 34232015.00 Occupancy Type: permit is issued. 91(�� APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to huilding construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAY ROM LAST CALLED INSPECTIO indemnity and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may ac a against said City in consequence of the �� Issued by: Date: granting of this permit. Add it' ally, the applicant understands and will comply with all non -point source r lations per the Cupertino Municipal Cod , l8._RE-ROOFS: /Sectio9. Signature Date All roofs shall be inspected prior to any ro g materia ng installed. Ira roof is installed without first obtaining an in ctyon, 1 agr o re ove all new materials for inspection. � ElOWNER-BUILDERDECLARATION Date: �J Signature of Applica : hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I, 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, Business & Professions Code) I. as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should 1 use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Secti ns 25505, 25533, an 255 Section 3700 of the Labor Code, for the performance of the work for which this r f Z Owner or authorized agent• / �-� Y/ Date: J / permit is issued. I certify that in the performance of the work for which this permit is issued, I shall 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith complv with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 1 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 ARCHITECT'S DECLARATION indemnity and keep harmless the City of Cupertino against liabilities, judgments, costs. and expenses which may accrue against said City in consequence of the 1 understand my plans shall be used as public records. -ranting of this permit. Additionally, the applicant understands and will comply +ith all non point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9_ I3_ Signature Date 3 ITEMS OF 22 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 34232015.00 DATE ISSUED.......: 08/22/2011 RECEIPT #.........: BS000014513 REFERENCE ID # ...: 11050210 SITE ADDRESS .....: 10082 AMADOR OAK CT SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OWNER ............: SHAIN VADIM AND KARINA ADDRESS ..........: 10082 AMADOR OAK CT CITY/STATE/ZIP ...: CUPERTINO, CA 95014 OPERATOR: SylviaM COPY # : 1 RECEIVED FROM ....: DRAEGER CONST. 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 ---------- 375.00 ---------- 1.00 ---------- 0.00 ---------- 1.00 ---------- 0.00 1BSEISMICR VALUATION 375.00 0.50 0.00 0.50 0.00 1REROOFRES SQ FEET 9.00 126.00 0.00 126.00 0.00 TOTAL PERMIT ---------- 127.50 ---------- 0.00 ---------- 127.50 ---------- 0.00 VOICE ID DESCRIPTION -------- ---------------------------- 309 EXTERIOR LATH 601 ROOF TEAR OFF VOICE ID DESCRIPTION -------- ---------------------------- 311 SCRATCH COAT 602 ROOF PLYWOOD NAIL 604 ROOF IN -PROGRESS 605 FINAL REROOF CUPERTINO REROOF PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildinata'�cupertino.ora ol-Y�K e r- I PDl mr-r Annl)�CC74ok— AFN# ov7Z- icvxa-�Crfla-/g riLl/012-Z,/0 X32 io z 3 - z-t�►� OWN>Zt� t �ltAME /A5AA, - ` PHONE � -S-3I S� E-MAIL D STREET ADRESS � STA � v or, FF 2 p GAO r AP CANTAj PHONE E-MAIL STREEDRi,$P ZIP FAX _5*STATE, (❑OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT C CTQRN LI NUMB LIJgEN$�TYP£ BUS. LIC. # V L GL `'� COMPAOA1.4E '/ �G �O ' E-MAIL FAX /j STREETkrB, w'QY 5 I C STATE !V_ _ 12- `„T/` ff — ✓+ t�� / ARCHITECT/ENGINEERNRME LICENSE BUS. LIC. # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY. STATE, ZIP PHONE USE OF ErSFD or Duplex ❑ Multi -Family ROOF A A: VALUATION: ❑ Commercial Ql� t` �'� STRUCTURE: _ 3 l.� I v EXISTING ROOF TYPE: UILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER (SPECIFY) REMOVE /REPLACE ❑ YES IF NO.PLYWOOD 1 w, 11PLYWD ElOSB PITCH ROOF O *LAYERS: THICKNESS: ❑ 5/8" TYPE: 5a CDX 12 CLASS: A PROPOSED ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ;gpTHER ICC -ES REPORT # DESCRIPTION OF WORK: r By my signature below, I certify to each of the foll ng- I am the property owner or authorized agent to act on the property o er's behalf. have read this application and the information I have provide rT . I have ?ead the Des tion of Work and verify it is accurate. I agr to comply th all applicable local ordinances and state laws relating to ljuildi co s on. I riz a en 'ves of Cupertino tc enter the abo prope..r :or inspection purposes. Signature of Applicant/Agent: Date: S SUPPLE ORMATION REQUIRED -- ..� 'Oiro�I. Rte- _ Ifbuilding is associated with a Home Owner's Association, provide letter of approval from HOA.Rr _ Provide Planning approval to verify if there any restrictions. �•�'T?'F'SS -,, �. ❑ P,LA'23NIIdG PL9NREVII±'W - _ Prov: copy of Manufacturer's Installation Specifications. jx.. ❑ =� Y 0 Provide signed copy of Cupertino's Tear -Off Policy. :t- ReroofApp_2011.doc revised 03/02/11 ys