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11050215CITY OF CUPERTINO BUILDING PERMIT BI ILDING ADDRESS: 10142 AMADOR OAK CT CONTRACTOR: DRAEGER PERMIT NO: 11050215 CONSTRUCTION INC OWNER'S NAME: TISH HELEN 605 COMMERCIAL ST DATE ISSUED: 08/22/2011 OW'NER'S PHONE: SAN JOSE, CA 95112 PHONE NO: (408)536-0420 ❑ LICENSED CONTRACTOR'S DECLARATION F— F— r— BUILDING PERMITINFO: BLDG ELECT PLUMB License Class Lic. # F-� MECH RESIDENTIAL COMMERCIAL Contractor Date C 1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REROOF, 950 SQUARES, SINGLE PLAY TPO OVERLAY (commencing with Section 7000) of Division 3 of the Business & Professions WITH 2 LAYER FR -10 BARRIER Code and that my license is in full force and effect. 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 perlivmance of the work for which this permit is issued. 1 have and will maintain Workers Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for tys permit is issued. T1'11 APN Number: 34232020.00 Occupancy Type: 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 to building construction, and hereby authorize representatives of this city to enter WITHIN 180 DAYS OF PERMIT ISSUANCE OR upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS R M LAST CALLED INS N. indemnify and keep harmless the City of Cu ertino against liabilities, judgments, ; 711 costs, and expenses which may accrue a st said City in consequence of the �x granting of this permit. Additional] e applicant understands and will comply Issued by: Date: with all non -point source regul s per th u ertino Municipal Code, Section 9.18. 51 RE -ROOFS: Signature_ Date l J All roofs shall be inspected prior to any ro aterial being installed. If a roof is installed without first obtaining an i ection, gree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION Signature of Applica ate: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I 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 I 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 I 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, Seca 1, ns 25505, 5533, and 2553 Section 3700 of the Labor Code, for the performance of the work for which this,�� lie' permit is issued. Owner or authorized agen Date: 1 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 comply 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 CF. RTI FICATI0N Lender's Address 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 ofthis 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, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. Granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 1) 18. Signature _ Date 3 ITEMS OF 22 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 34232020.00 DATE ISSUED.......: 08/22/2011 RECEIPT #.........: BS000014513 REFERENCE ID # ...: 11050215 SITE ADDRESS .....: 10142 AMADOR OAK CT SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OWNER ............: TISH HELEN ADDRESS ..........: 10142 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 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT AMOUNT --------------- 1,007.50 --------------- 1,007.50 VOICE ID DESCRIPTION -------- ---------------------------- 309 EXTERIOR LATH 601 ROOF TEAR OFF REFERENCE NUMBER -------------------- 0753 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 • buildinaacuoertino.ora I' -r enr%9aca .Q� dr— I APN# ��2 �2— D i ) 1 lJ 0 iu�r z-10,0-/0 i(L,�oiLL,/ 32 io z OWNER;ME PHGNE n zS 31 S� E-MAIL STREETADDRESS lY(` AP CANT E-MAIL STREET DRF.,$ .STATE, � P � (❑OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT C CT(2RNAME � LI NUMB LI�EN$jr E BUS. LIC. # (� GC 5 COMP�YA�vIE V ,n/�j �O E-MAIL FAX ST �' T, g�� l !J_ _ �vl ✓+ 5 ARCHITECCT/ENGINEER NAME LICENSE BUS. LIC. # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF SFD or Duplex ❑ Multi -Family ROOF A A: VALUATION:I .5 ❑ Commercial 0 r -5f't` T( STRUCTURE: h V-, EXISTING ROOF TYPE: UILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER (SPECIFY) REMOVE /REPLACE ❑ YES IF NO. PLYWOOD g w, ❑ PLYWD ❑ OSB PITCH:T) 12 ROOFA 54 O # LAYERS: THICKNESS: ❑ 518" TYPE: RfCDX ' CLASS: PROPOSED ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES 9�07`rIER ICC -ES REPORT # DESCRIPTION OF WORK: moi` ! a r Ol/�f/ �. l Z -e!- f=X /6 P� 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 ' rr t. I have Fead the Des ' tion of Work and verify it is accurate. I agr to comply th all applicalie local ordinances and state laws relating to lylildi co s on. I riz a enter 'ves of Cupertino tc enter the abo eproperr! :or inspection purposes. Signature of Applicant/Agent: Date: S G SUPPLE ORMATION REQUIRED F,y a0:1 - .i _ If building is associated with a Home Owner's Association, provide letter SIZP OVZR_- 'srFs+^IiN=9 ^ BUII2)ING'� AN RENEW` 1," of approval from HOA. Provide Planning approval to verify if there any restrictions. :i.� fid,—�•e�, �.�» �— a� ��:...,t,.� were_-^.-s.e—� -C^ F � Prov: copy of Manufacturer's Installation Specifications. ,� �'ItESS -., j❑ PLA7YNING PI:�IVREYIEVP 1zxE`4�Px - Provide signed copy of Cupertino's Tear -Off Policy. _ - u ❑ oTs _ _ ReroofApp_2011.doc revised 03/02/11 YS