11050244 CITY OF CUPERTINO BUILDING PERMIT
lit 11 DING ADUREss: 10013 LONG OAK LN CONTRACTOR:DRAEGER PERMIT NO: 11050244
CONSTRUCTION INC
0N%NE:R'S NA.IE: CHUN-TEN& CHIENLING KAO 605 COMMERCIAL ST DATE ISSUED:08/22/2011
OWNER'S PHONE: SAN JOSE, CA 95112 PHONE NO:(408)536-0420
LICENSED CONTRACTOR'S DECLARATION �
n BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# � _ w
S Date MECH RESIDENTIAL COMMERCIAL
Contractor / 2 /
1 hereby affirm that I licensed under the provisions of Chapter 9 JOB DESCRIPTION: RE-ROOF 9 7 SQ-1/2"PLYWOOD,TPO OVERLAY WITH 2
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.
I hereby affirm under penalty of perjury one of the following two declarations:
I h:;,;and will maintain a certificate of consent to self-insure for Worker's
t ompcnsation,as provided for by Section 3700 of the Labor Code,for the
perlonnancc 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 w h this APN Number:34232055.00 Occupancy Type:
permit is issued f r s
:1PPLICAN"f CFR'I'IFICA'TION _ (�/i-
1 cc;tdthat I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
I agree to armply with all city and county ordinances and state laws relating
to huil WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to uildin�amstrucuon,and hereby authorize representatives of this city to enter
upon the above mentioned property I*inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the rty of Cupertino against liabilities,judgments,
costs.and expenses which m accrue against said City in consequence of the
grantins of this permit. itionally,the app nt understands and will comply Issued by: Date:
with at;non-point sour• regulations per Cuperrtino Municipal Code,Section
�9-i3
jSignature _ ~ Date 2 �/ All roofs shall be inspected prior to an,/roingOmateri ing installed. If a roofis
installed without first obtaining an insp ,l anate:
remove all new r aterials for
inspection.OWNER-BUILDER DECLARATIONSignature of Applicant: 2s
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 BE7"1'ER
I,as owner of tiic property.or my employees with wa-es as their sole compensation,
w ill do the work.and the structure is not intended or offered for sale(Sec.7044.
Business&1'ro essions Code)
1. as owner of the property am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
1 cont u n_t the project tSec 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
iiao,v and will maintain a Certificate of Consent to sell'-insure for Worker"s material. Additionally,should I use equipment or devices which emit hazardous
I i ornpcnsation.as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
perlorinance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,.Chapter 9.12 at d
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sect ns 25505,25533,and 25534
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
Owner or authorized agent / � Dat �S /
i 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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become srub.iect 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
10:11M ith oomph with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) —
`i Lender's Name
APPLICANT CERTIFICATION Lender's Address
!certify that I have read this application and state that the above information is
urrcct 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 ti,c abovc mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION I
�md enutify and keep harmless the City of Cupertino against liabilities,judgments,
t
cos,s-and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
t granting ofthis permit.Additionally,the applicant understands and will comply
wJill a1!non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional_
t
Si caturc Date
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 950143255
(408)777-3228• FAX(408)777-3333 • building(a�cuperiino.org
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FAX
AP ICANT 11j f PHONE r�-L E-MAM
STREE�DRF�$ � P � �T C .STATE,ZIP � 7' FAX .
❑OWNER (El OWNER-BUILDER ❑ OWNER AGENT J;CONTRACTOR ❑CONTRACTOR AG rr ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
C CTQR NAME LI NS NUMB LIEN$ TYPE BUS.LIC.#
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COMP �A;.QE Cbi!V c LQ E-MAIL FAX
STREE
I V T! CITY,SI A
ARCI-ITEMENGINFEER NAME LICENSE BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CrI-Y,STATE,ZIP PHONE
USE OF SFD or Duplex ❑ Multi-Family ROOF AREA: VALUATION:
STRUCTURE: ❑
Commercial `!tr-n f
EXISTING ROOF TYPE: UILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY)
REMOVE/REPLACE El YES IF NO, PLYWOOD �'h" ❑ PLYWD ❑ OSB PITCH: ROOF
O #LAYERS THICKNESS: ❑ 5/8" TYPE: 5a CDX '12 CLASS: A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLESOTHER ICC-ES REPORT#
DESCRIPTION OF WORK: 5;1 / OV�Y GL C ' Z /G
By my signature below,I certify to each of the foll n I am the property er or authorized agent to act on the property owner's behalf I have read this
application and the information I have provided i co ct. I have read th escriptio of Work and verify it is accurate. I pree to comp] th all applicable local
ordinances and state laws relating to bui ng n ction. I riz resentativ s of Cupertino tc enter the ab Ted prope ;for inspection purposes.
Signature of Applicant/Agent Date: /
SUPPLEMEY INFORMATION REQ
_If building is associated with a Home Owner's Association,provide letter
of approval from HOA. owR Bu>IIIVG P�nN REW
_Provide Planning approval to verify if there any restrictions. �7iss r1 nlvt�>zacpLA7v>x�vlEw
s �
:�Provcopy of Manufacturer's Installation Specifications. n , Q �tnEPi
Provide signed copy of Cupertino's Tear-Off Policy. 's OTHFR -
r
Rerooflpp 2011.doc revised 03/02111