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11050267CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10133 AMADOR OAK CT CONTRACTOR: DRAEGER PERMIT NO: 11050267 CONSTRUCTION INC ONN'NLR'S NAME: NAUM ROYTMAN 605 COMMERCIAL ST DATE ISSUED: 08/22/2011 OWNER'S PHONE: SAN JOSE, CA 95112 PHONE NO: (408)536-0420 ❑ LICENSED CONTRACTOR'S DECLARATION (W f - License Class � � � � BUILDING PERMIT' INFO: BLDG ELECT PLUMB Lic. # MECH RESIDENTIAL COMMERCIAL Contractor % _-&- < Date i hereby. ftirIn 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. 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 fo w i�ht Permit is issued. APN Number: 34232022.00 Occupancy Type: APPLICANTCERTIFICATION 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 building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAY F OM LAST CALLED INSPE TI N. indemnity and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the eranung of'tllis permit. Addition- , tRe applicant understands and will comply Issued by: Date: with all non -point source reg ions.per the Cupertino Municipal Code, Section 9.18 Signature — Date �S � % RE -ROOFS: All roots shall be inspected prior to any r9pftpg material being installed. If a roof is installed without first obtaining an ins tiori, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION_ Signature of Applica Date: I 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 ,+ ill 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 1 performance ofthe 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, Sec ions 25505, 25533, and 25Z Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent. l// f�G Date: G permit is issued. I certify that in the performance of the work for which this permit is issued, I shall not cmplo� any person in any manner so as to become subject to the Worker's Compensation laws of Calitornia. 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. 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, 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. °ranting of this permit. Additionally. the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9 18 Sienauuc Date 3 ITEMS OF 21 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ........: 34232022.00 DATE ISSUED.......: 08/22/2011 RECEIPT 4.........: BS000014515 REFERENCE ID # ...: 11050267 SITE ADDRESS .....: 10133 AMADOR OAK CT SUBDIVISION ...... CITY .............. CUPERTINO IMPACT AREA ...... OPERATOR: SylviaM COPY # : 1 OWNER ............. NAUM ROYTMAN ADDRESS ..........: 10133 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 lU (33 REROOF PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingacupertino.orp ) ) 05 CD2Co-- — Pnn=r-r.nnnacc f�- QV �u 0 r7 1 APN# .� •yrs--�--�tr3-�6�--�/ 3- 3�2 3 2 0 2 �Z OWN.....r U ria Nauru �_10� tyikn O E-MAIL 1S.- STREET ADDRESS STATE TrIP /�, FAX r 2-2-U-70 Y -e APWCANT rIJAPHONE � U— � EMAIL STREEj_40DRE,$S � � S l (El .STATE, ZIP � z' FAX ❑ OWNER OWNER -BUILDER ❑ OWNER AGENT 5<C/0NT71CTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT C CT(IR NAME LI NIJIvffi LI EN$� TYPE BUS. LIC. # �l a 5 COMP,6EX_E / E-MAIL FAX [� �Y ' A , pY �� !! T CrrY. STATE !V_ ` V` iy =12 / ARCHITECT/ENGINEER NAME LICENSE LICENSE BUS. LIC. # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF bKrD or Duplex ❑ Multi -Family ROOF A: VALUATI, N: �� ED Commercial / ; ' 'th STRUCTURE: (� EXISTING ROOF TYPE: UILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER (SPECIFY) REMOVE CE ❑ YES IF NO.PLYWOOD W' ❑ PLYWD 13OSB PITCH ROOF O # LAYERS: THICKNESS: ❑ 5/B" TYPE: R1 CDX 12 CLASS: A PROPOSED ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ;9pT ER ICC -ES REPORT # DESCRIPTION OF WORK: r By my signature below, I certify to each of the foll ng: jafm the property owner ed agent to act on the property owner' behalf. this �haad application and the information I have provided ' correc have read th�Desc ' on ofWo 1- and verify it is accurate. I agree comply Witicable local ordinances and state laws relating to buildin nstru 'on. I authorize rep ntatives of Cu ertine tc enter the above-' pyOper for'purposes. Signature of Applicant/Agent•. Date: C SUPPLEMENTAL ORMATION REQUIRED k.., ..i�-`�`. < �.i�y�w"`�t- . w. �FFdCE-vXJ,SFN�rcrTV��i3t� — If building is associated with a Home Owner's Association, provide letter OVE '-TB ;;C0UXMR w ❑ �UII�ING PIAN REVIEW" z" of approval from HOA. — Provide Planning approval to verify if there any restrictions. 3 n EXPRESS o _ y ��aivxv nec PLaiavzER — Provide copy of Manufacturer's Installation Specifications. 3_ IaEnE F rovide signed of Cu ertino's Tear-OffPolicy. i copy P Y f_ C7 F :_: _ OTHER. — Y sem"'— .. 'L•.� �. _ _ Z�'�� lye'.e ReroofApp_2011.doc revised 03/02111 V5