11050230 r
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22694 LIBERTY OAK LN CONTRACTOR:DRAEGER PERMIT NO: 11050230
CONSTRUCTION INC
OWNER'S NAME: KAO ROXANNE AND JACK 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 Class — Lie.#
��y,� �� MECH RESIDENTIAL COMMERCIAL
Contractor j'�'«/��Z� Date .� t
JOB DESCRIPTION: RE-ROOF 10.4 SQ-1/2"PLYWOOD,'1'PO OVERLAY WITH
hereby affirm that I 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
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 this APN Number:34232040.00 Occupancy Type:
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 DAY FROM LAST CALLED INSPEC ION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs.and expenses which may accrue inst said City in consequence of the Issued by: l/G G Date:
granting of this permit. Additiona ,the pplicant understands and will comply
with all non-point source regul ons the ertino Municipal Code,Section
9.18.
_ RE- FS:
Signature ' Date �S j All roofs shall be inspected prior to any o ng material being installed.If a roof is
installed without first obtaining ani a ton,I agr to remove all new materials for
inspection.
r
❑ OWNER-BUILDER DECLARATION
Signature of Applica Date: �� f
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 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
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 1 store or handle hazardous
I have and will maintain a Certificate of Conscnt 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
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipa ode,Chapter 9.12•and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Se ions 25505,2553 ,an 5534.
Section 3700 of the Labor Code,for the performance of the work for which this r Date
Owner or authorized ager / �
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
not employ y
an person in an manner so as to become subject to the Worker's
Compensation nlaws 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. 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 of the 1 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 . . . . . . . . : 34232040 . 00
DATE ISSUED. . . . . . . : 08/22/2011
RECEIPT #. . . . • • • • • : BS000014525
REFERENCE ID # . . . : 11050230
SITE ADDRESS . . . . . : 22694 LIBERTY OAK LN
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA
OWNER . . . . . . . . . . . . : KAO ROXANNE AND JACK
ADDRESS . . . . . . . . . . : 22694 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
CUPERTINO (408)777-3228• FAX(408)777-3333•building aacuper[ino.org
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AP ICANT Iq PHONE E-MAIL
STREEDREq P� STATE, ZIP ?' FAX
510 064
ElOWNER i❑1'VOWNER-BUILDER 1:1OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINE ER ❑ DEVELOPER ❑TENANT
C CTQR NLI 5 NUMB LI Elft TYPE BUS.LIC.90 #
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E-MAIL FAX
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ARCHITECT/ENGINEER NAME LICENSE BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or Duplex ❑ Multi-Family ROOF AREA: �p,� VALUATION: p /,2IP'ZLP.9 1 (_h
STRUCTURE: ❑ Commercial t'Q'� 59' f "" �� tJ 'Z- IU La
`
EXISTING ROOF TYPE: UILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY)
REMOVE/REPLACE ❑YES IF NO, PLYWOOD W, ❑ PLYwD ElOSB PITCH ROOF
5KNO #LAYERS THICKNESS: ❑ 5/8" TYPE: RE CDX '12 CLASS: A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES g�0'I-r1ER ICC-ES REPORT#
DESCRIPTION OF WORK moo O liter i
By my signature below,I certify to each of the follo ' g: the property er o authorized agent to act on the property owner's beho. I have read this
application and the information I have provided is rrec. I h read the escriptio of Work and verify it is accurate. I agree to com with all applicable local
ordinances and state laws relating to buildi co on. I authbrize presentati sof Cupertino tc enter the above-ide 'feed pro rt for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEME ORMATION REQUIRED A-l"�W-0 1NN,vi: � 'IM, .m
_If building is associated with a Home Owner's Association,provide letter
of approval from HOA. oytuIibINGLAN
—Provide Planning approval to verify if there any restrictions. �_1S - �, PlaicLAZvx�vlEa;
< p -
Provide copy of Manufacturer's Installation Specifications.
.,.1��STANNI}itTtD � - ❑ EIRE"I)EPT
rovide signed copy of Cuper-tino's Tear-Off Policy. '
4 �
ReroofApp_2011.doc revised 03/02/11