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11050226 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22682 LIBERTY OAK LN CONTRACTOR: DRAEGER PERMrr NO: 11050226 CONSTRUCTION INC OWNER'S NAME: RAVI SANK-AR PULIAMPATTAYIL 605 COMMERCIAL ST DATE ISSUED:08/22/2011 OWNER'S PHONE: SAN JOSE,CA 95112 PHONE NO:(408)536-0420 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG� ELECT� PLUMB License Clas — G Lic.# 0 r— f MECH RESIDENTIAL COMMERCIAL Contractor � 1U ,� Date l� JOB DESCRIPTION: RE-ROOF 10.4 SQ-1/2"PLYWOOD,TPO OVERLAY WITH 1 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. 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 Section 3700 of the Labor Code,for the performance of the work for which this APN Number:34232043.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION certtty 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 ROM LAST CALLED INSPE TIO indemnity 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: C Date: .ranting of this permit. Additi ly,the applicant understands and will comply with all non-point source r lations per the Cupertino Municipal Code,Section 9 18, RE-ROOFS: Signatur _ Date All roofs shall be inspected prior to any roofing C'rial being installed. If a roof is installed without first obtaining an inspectio ee to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION �� Signature of Applicant: 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 1.as o%Nner of the properq,or my employees with wages as their sole compensation, ill do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) L 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(x)should 1 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 will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 2553 Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date: 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 ofexemption,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 toriliwith 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence ofthe 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 9 18. Signature Date CITY OF CUPERTINO 3 ITEMS OF 21 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 34232043 . 00 DATE ISSUED. . . . . . . : 08/22/2011 RECEIPT #. • • . • • . • . : BS000014525 REFERENCE ID # . . . : 11050226 SITE ADDRESS . . . . . : 22682 LIBERTY OAK LN SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : RAVI SANKAR PULIAMPATTAYIL ADDRESS . . . . . . . . . . : 22682 LIBERTY OAK LN CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 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 VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 309 EXTERIOR LATH 311 SCRATCH COAT 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 604 ROOF IN-PROGRESS 605 FINAL REROOF REROOF PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333•building aa..cuper'tino.org CUPERTINO 50 Z2 12,Y-k 8 9- I 8� b*k Gt Gi APN# (� Py(,TC!`T ATlT19:CC ' G�wb(+•�'-CWS � r_ / / •� fr ��/�` EMAIL Jai STREET_ADDRESS FU STA ^_ FAX AP (CANT N PHONE/ E-MAM &4- FAX ST REET_4�BDRIffl1 A^ p j !_ / ❑OWNER ❑ OVR� OWNER-BUILDER ❑ OWNER AGENT CO/NTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT C C QR N LI SMB LIEN TYPE BUS.LIC.# E MAIl ---��jj FAX CGbTP OS YV`G V r S17tEETj�8 C �! Et Qy r� �� l Vl22 O ARCHITECT/ENGINEER NAME LICENSE BUS.LIC.# E-MAIL FAX COMEADDRESS STR CITY,STATE,ZIP PHONE SFD or Duplex ❑ Multi-Family ROOF AREA: VALUATION: 2(P2� USE OF 0, 59 � `�_o STRUCTURE: -)WOOD ( EXISTING ROOF TYPE: UII.T-UP ROOF ❑ASPHALT SHINGLES El WOOD SHAKES ❑WOOD SHINGLES El OTHER(SPECIFY) REMOVE/REPLACE ❑FTI IF NO, PLYWOOD h" ❑ PLYWD ❑ OSB PITCH ROOF 56N #LAYERS: THICKNESS: ❑ B. TYPE: CDX :12 CLASS: A �( ICC-ES REPORT# PROPOSED ROOF TYPE: 1-1BUILT-UPROOF El ASPHALT SHINGLES 11 WOOD SHAKES EJp' WOOD SHINGLES OT-i�R DESCRIPTION OF WORK-' leg By my signature below,I certify to each of the folio�,.�,, Ijha, the property er o authorized agent to act on the property owner's beh I have read this application and the information I have provided is e read the escriptio of Work and verify it is accurate. I agree tocogall applicable local ordinances and state laws relating to buildi con. auth6rize presentati sof Cupertino tc enter the above-ide 'feed pro r; for inspection purposes. Signature of Applicant/AgentDate 6/ SUPPLE ORMATION REQUIRED kit* "''� — _ L41— If building is associated with a Home Owner's Association,provide letter of approval from HOA. ovER1�F�DII1k BU1LbIIdG PLAN REvvzEw Provide Planning approval to verify if there any restrictions. g = PLAIiNWG pLANREVIEW _Provide copy of Manufacturer's Installation Specifications. STANDAR- D FIRE'DEPI rovide signed copy of Cupertino's Tear-Off Policy. ReroofApp_2011.doc revised 03/02/11