11050266CITY OF CUPERTINO BUILDING PERMIT
Bt H.DING ADDRESS: 10123 AMADOR OAK CT
CONTRACTOR: DRAEGER
PERMIT NO: 11050266
CONSTRUCTION INC
OWNER'S NAME: HOOD SARAH S AND WEST ROBERT A
605 COMMERCIAL ST
DATE ISSUED: 08/22/2011
OWNER'S PHONE:
SAN JOSE, CA 95112
PHONE NO: (408)536-0420
❑ LICENSED CONTRACT'OR'S DECLARATION
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BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class �� Lic. L// /7 (�'/O
F—
MECH RESIDENTIAL COMMERCIAL
Contractor Gly. L(, Date
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
JOB DESCRIPTION: RE -ROOF 10 SQ- 1/2"PLYWOOD, TPO OVERLAY WITH 2
(commencing with Section 7000) of Division 3 of the Business & Professions
LAYER FR -10 BARRIER
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
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
permit is issued.
[24�
APN Number: 34232023.00
Occupancy Type:
APPLICAN I CERTIFICATION
I certil'y 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 building construction, and hereby authorize representatives of this city to enter
L111011 the above mentioned property for inspection purposes. (We) agree to save
180 DAYS LAST CALLED INSPE TI N.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
7M
costs. and expenses which may accrue against said City in consequence of the
�2
��
ar ming of this permit. Additionally, applicant understands and will comply
Issued by: Date: �J
with all non -point source regulati .Per the Cupertino Municipal Code, Section
9.18.
�' �2 ��
RE -ROOFS:
Signature Date
All roots shall be inspected prior to any roo material being installed. If a roof is
installed without first obtaining an insp iov,, 1 agree to remove all new materials for
inspection. j
f �2,
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
1 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
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:
Ilealth & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate ofConsent 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
pertonnance of the work for which this permit is issued
will maintain compliance with the Cupertino Municipalde, Chapter 9.12 and
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
the Health & Safety Code, Sections f25505, 25533, and 2 4.
permit is issued.
Owner or authorized agenlKLIIL`�✓/� Date ?
I certify that in the performance of the work for which this permit is issued, 1 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 CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. ! 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.
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
w ith all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
Si, nature Date
I
3 ITEMS OF 21
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 34232023.00
DATE ISSUED.......: 08/22/2011
RECEIPT #.........: BS000014515
REFERENCE ID # ...: 11050266
SITE ADDRESS .....: 10123 AMADOR OAK CT
SUBDIVISION ......
CITY CUPERTINO
IMPACT AREA ......:
OPERATOR: SylviaM
COPY # : 1
OWNER ............: HOOD SARAH S AND WEST ROBERT A
ADDRESS ..........: 10123 AMADOR OAK CT
CITY/STATE/ZIP ...: CUPERTINO, CA 95014-5605
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
10.00
140.00
0.00
140.00
0.00
TOTAL PERMIT
----------
141.50
----------
0.00
----------
141.50
----------
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
16123
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE A CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • buildino CDCUDeriino.org
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❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
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ARCHITEECCT/ENGINEER NAME
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BUS. LIC. #
COMPANY NAME
E-MAIL
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STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF bSfD or Duplex ❑ Multi -Family ROOF
A: VALUATI, N:
STRUCTURE: El Commercial 0` ' 1` `
EXISTING ROOF TYPE: UILT-UP ROOF ❑ ASPHALT SHINGLES
�.
❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER (SPECIFY)
REMOVE /REPLACE ❑ YES
IF NO.
PLYWOOD'h" ❑ _7PLYWD
❑ OSB
PITCH
ROOF
O
# LAYERS:
THICKNESS: ❑ 5/8"
TYPE: CDX
12
CLASS: A
PROPOSED ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHIINGLES
❑ WOOD SHAKES ❑ WOOD SHINGLES OTHER
ICC -ES REPORT #
DESCRIPTION OF WORK
all
Leg
By my signature below, I certify to each of the foll ng: I the property owner ed agent to act on the property owner' behalf. I ha ad this
application and the information I have provided correc have read the Desc on of Wo k and verify it is accurate. I agree comply with app licabi2local
ordinances and state laws relating to buildi nstru •on. I authorize rep tatives of Cu ertino tc enter the above per"; for' pection purposes.
Signature of Applicant/Agenr
Date: C l/
SUPPLEMENTAL ORMATION REQUIRED
k� s�
— If building is associated with a Home Owner's Association, provide letter
of approval from HOA.
r OV,ER..TH�:DIIh'�FR�
❑ VBUII.�ING''piAA*�RE'VIEW� '
— Provide Planning approval to verify if there any restrictions.
Q EXPRESS -
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Provide copy of Manufacturer's Installation Specifications.
t� {e ..�-
�Z?�'NNIING PLA2N RENTER'+
_
rovide signed copy of Cupertino's Tear -Off Policy.
Reroof.4pp 2011.doc revised 03/02111