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11050237CITY OF CUPERTINO BUILDING PERMIT BI llDING *kDDRESS: 22568 LAZY OAK CT CONTRACTOR: DRAEGER PERMIT NO: 11050237 CONSTRUCTION INC OWNER'S NAME: XIAGUANG WANG & PING YU 605 COMMERCIAL ST DATE ISSUED: 08/22/2011 OWNER'S PHONE: SAN JOSE, CA 95112 PHONE NO: (408)536-0420 ❑ LICENSED CONTRACTOR'S DECLARATIONr F_ BUILDING PERMIT INFO: BLDGELECT PLUMB License Class Lic. # I— I— I— MECH RESIDENTIAL COMMERCIAL Contractor .1 415 Date JOB DESCRIPTION: RE -ROOF 102 SQ- 1/2"PLYWOOD, TPO OVERLAY WITH 2 hereby affirm that am licensed under the provisions of Chapter 9 LAYER FR -10 BARRIER (commencing with Section 7000) of Division 3 of the Business & Professions 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 performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $375 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 34232006.00 Occupancy Type: Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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 building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS R M LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the Issued by: Date: / Warning of this permit. Additio y the applicant understands and will comply with all non -point source re atio pert up rtino Municipal Code, Section If 9.18. RE -ROOFS: Signator Date All roofs shall be inspected prior to an roofing material being installed. If a roof is installed without first obtaining a4_n ection, I ag �to remove all new materials for inspection. r ❑ OWNER -BUILDER DECLARATION Date: Zai Signature of Applican 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) 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 1 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 1 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, Se ions 25505, 25533, and 255361: r/t Section 3700 of the Labor Code, for the performance of the work for which this5�� Owner or authorized agent `/l zC� Date: �S 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If, after making this certificate of exemption, I 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 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 I understand my plans shall be used its 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 9.18 Signature Date 3 ITEMS OF 15 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN 34232006.00 DATE ISSUED.......: 08/22/2011 RECEIPT #.........: BS000014519 REFERENCE ID # ...: 11050237 SITE ADDRESS .....: 22568 LAZY OAK CT SUBDIVISION ...... CITY CUPERTINO IMPACT AREA ...... OWNER ............: XIAGUANG WANG & PING YU ADDRESS ..........: 22568 LAZY 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 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 2 �/_5lok REROOF PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • buildingacupertino.org 0562,3-4- ___V ATTR➢]LCC e/1 Z�f`� PDn=c i.� �I� /, / n ?Z-5 �2Y '-2'Z (O' Zz L 2 _ 'Z 2. (�Qd' APN # 1 1� �J 2 OBJ L Lvyt E-MAIL STREEAD S / �rrY, FAX O 1 -e ��(�PHONE (� AP CANT Aj E-MAIL 7 �r -i D- 3 STREET.AOD 'AA �� STATE, ZIP FA}t ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT RCONTRAcToR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT C CT(tR N � LI NS NUMB E BUS. LIC. # to a —$� 5 COMP��AIvIE � 'n/G /_O E-MAIL FAX STREET, e (b p l ySTATE Lt4 ARCHITEECT/ENGINEERNAME LICENSE BUS. LIC. # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF D or Duplex ❑ Multi -Family /ROO9F AREA: VAT ITA -111 / L(p 2� a G G( STRUCTURE: ❑ Commercial ` eJ/ ". �j ,� lJ - ` (� 11 EXISTING ROOF TYPE: UILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ' ❑ OTHER (SPECIFY) REMOVE /REPLACE ❑ YES IF NO, PLYWOOD h" ❑ PLYWD ❑OSB PITCH ROOF O #LAYERS THICKNESS ❑ 5/8" TYPE: CDX 12 CLASS: CA PROPOSED ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES )! OTHER ICC -ES REPORT # DESCRIPTION OF WORK: Q / / :z e By my signature below, I certify to each of the follo ng: jaKthe property owne au rized agent to act on the property owner's behalf. I have read this application and the information I have provid i Ire . have read the Des ption of ork and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildi c on. I au ere entatives Cupertino tc enter the above-ide led prope for inspection purposes. Signature of Applicant/Agent: Date:7-11 SUPPLEMENTAL INFORMATION REQUIRED s..GAN .M., _.. _ If building is associated With a Home Owner's Association, provide letter ctslsPj" �v�R BIIaz»rl�iAri..Rv* of approval from HOA. Provide Planning approval to verify if there any restrictions. h FXPtcc$ 0 Provide copy of Manufacturer's Installation Specifications. W - PZANi�IG PLANREVTEW nFPx - rlx L',frr'Ovide signed copy of Cu ertino's Tear -Off Policy. xOTHFA. ReroofApp_2011.d6c revised 03/02/11 V5