11050243 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10003 LONG OAK LN CONTRACTOR:DRAEGER PERMIT NO: 11050243
CONSTRUCTION INC
OWNER'S NAME: NISAR& SHAHLA ALI 605 COMMERCIAL ST DATE ISSUED:08/22/2011
OWNER'S PHONE: SAN JOSE, CA 95112 PHONE NO:(408)536-0420
❑ LICENSED CONTRACTOR'S DECLARATION F— r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class -3-9 Lic.# &/7 &10 � ]� �
MECH RESIDENTIAL COMMERCIAL
Contractor_ `1 Date L,?
JOB DESCRIPTION: RE-ROOF 9.7 SQ- I/2"PLYWOOD,TPO OVERLAY WITIi 2
I herebN affirm that am licensed under the provisions of Chapter 9 LAYER FR-10 BARRIER
(Confile nciup,with Section 7000)of Division 3 of the Business& Professions
Code and that ntv 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 whicl i� APN Number:34232056.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I ccrtif) that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
comet. 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 INSPECTION.
uuicmnilj and keep harmless th° i of-Cupertino against liabilities,judgments,
costs.and evpenscs which y accr e against said City in consequence of the -�
erinting of this permit dition�l1�,the applic understands and will comply Issued by: '& Date:
with all non-point sou e regal• ons per th ape tiro Municipal Co e,Secti n
RE- OFS:
Signature Date �5 �1 All roofs shall be inspected prior to a roofip'g materi eirlg installed. If a roof is
installed without first obtaining an i specti I agr° to remove all new mat,rr Is for
inspection. /
❑ OWNER-BUILDER DECLARATION _
Signature of Applicant. / ate:
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
L as owner of the property,or my employees with wages as their sole compensation,
will du the work,and the structure is not intended or offered for sale(See.7044,
P,usin SS&Protessions Code)
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 695 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I 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 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 I
pcoOrmancc of the\,ork for which this permit is issued. will maintain compliance with the Cupertino Municipal ,Chapter 9.12 and 01
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Se ns 25505,25533,and 255 Co4.
tiection 3700 of the Labor Code, for the performance of the work for which this I � 4-Z
(�Owner or authorized agent � Date:
permit Is issued.
I ccrtifV 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 laxas of California. If,after making this certificate ofexemption,I CONSTRUCTION LENDING AGENCY
become suhIce[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
lorthwrth 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 certil) that I have read this application and state that the above information is
correct. 1 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.
erarting of this permit.Additionally,the applicant understands and will comply
N\ith all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional_
9 19
S121laturc Date
CITY OF CUPERTINO
3 ITEMS OF 21 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec : Twp : Rng: Sub: Blk: Lot :
APN 34232056 . 00
DATE ISSUED . . . . . . . : 08/22/2011
RECEIPT # . . . . . . . . . : BS000014506
REFERENCE ID # . . . : 11050243
SITE ADDRESS . . . . . : 10003 LONG OAK LN
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : NISAR & SHAHLA ALI
ADDRESS . . . . . . . . . . : 10003 LONG OAK LN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : DRAEGER CONSTRUCTIO
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(a�cuger'tino.orcl
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❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT R�CONTRACrOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑04GINEER ❑ DEVELOPER ❑TENANT
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ARCHITECT/ENGINEER NAME LICENSE BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY.STATE,ZIP ONE
USE OF SFD or Duplex ❑ Multi-Family ROOF AREA: VALUATION: _42I
STRUCTURE: ❑ Commercial V+
EXISTING ROOF TYPE: UILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY)
REMOVE/REPLACE ❑YES IF NO,
:PLZOODS 'h" ❑ PLYWD ❑ OSB PITCH: ROOF
#LAYERSTIES ❑ 5/8" TYPE: X '12 CLASS: A
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ICC-ES REPORT#
PROPOSED ROOF TYPE: ElBUILT-UPROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ;907IER
DESCRIPTION OF WORK:
By my signature below,I certify to each of the foll n I am the property ),erorauthorized agent to act on the property owner's behalf I have read this
application and the information I have provided' co ct. I have read th escriof Work and verify it is accurate. I eeto compl th all applicable local
ordinances and state laws relating to bui ng n ction. I riz resentof Cupertino tc enter the ab fled prope ,for inspection purposes.
Signature of Applicant/Agent: Date: G
t �Rr �CE
SUPPLEME INFORMATION REQ S �4
– - ouruv,c srxP�
If building is associated with a Home Owner's Association,provide letter _
of approval from HOA. oRzvt $i7IN�1A?iw
T _� � '�, •
_ 77-
Provide Planning approval to verify if there any restrictions. s5 ` plAli 'GPLANREYIEW
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_Provide copy of Manufacturer's Installation Specifications. -
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Provide signed copy of Cupertino's Tear-Off Policy. _ oTsrR..
ReroofApp_2011.doc revised 03/02/11