11050251 CITY OF CUPERTINO BUILDING PERMIT
131 H,DINC ADDRESS: 10063 LONG OAK LN CONTRACTOR:DRAEGER PERMIT NO: 11050251
CONSTRUCTION INC
O%NNER'S NAME: JACOBS MILTON AND ROSE 605 COMMERCIAL ST DATE ISSUED:08/22/2011
OWNER'S PHONE: SAN JOSE,CA 95112 PHONE NO:(408)536-0420
❑ LICENSED CONTRACTOR'S DECLARATION h I� I—
BIILDING PERMIT INFO: BLDG ELECT PLUMB
License Cla-s � Lic.# ( r— r
�Q pr,. MECH RESIDENTIAL COMMERCIAL
Contracto V L 'e 0 Date! s
)OB DESCRIPTION: RE-ROOF 9.7 SQ- 1/2"PLYWOOD,TPO OVERLAY WITH 2
1 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 hich this APN Number:34232050.00 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 DAYS ROM 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
ranting of this permit. Addit ally,the applicant understands and will comply Issued by: v` Date:
ith all non-point source r ulations per the Cupertino Municipal Code,Section
9 18.
r / RE- S:
SiEnature _Date �/ All roots shall be inspected prior to an ooting material being installed. If a roof is
installed without first obtaining an spect�en,I Dremove all new materials r
inspection. /
❑ OWNER-BUILDER DECLARATION
: � "
I herchy affirm that I am exempt from the Contractor's License Law for one of Signature of ApplicantDate:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
t.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
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
1 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
per!ornhance of the work for which this permit Is issued. will maintain compliance with the Cupertino Municipal bode,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,S2etins 25505,25533, d 34.
Section 3700 ofthe Labor Code,for the performance of the work for which this �/Owner or authorized agent �� Date:
pcnnit is issued. If
1 ccrtifi that in the performance of the work for which this permit is issued,I shall
not enhploy 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
heconrc suhlect 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
uxrect. I agree to comply with all city and county ordinances and state laws relating
t to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save
ndemnify 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.
.ranting 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.
SiL'nature Date
w
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTtNO (408)777-3228• FAX(408)777-3333 •building .cupertino.org
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❑OWNER C❑�OVWNv`ER-BUILDER ❑ OWNER AGENT R�CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
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ARCHITECIYENGINEER NAME LICENSE BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or Duplex El Multi-Family ROOF AREA: VALUATION:
STRUCTURE: ❑ Commercial �/r l ! � ! `v ? `+ �` S
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
5KNO 1 #LAYERS: THICKNESS: ❑ 5/8" TYPE: 9 CDX �'12 CLASS: A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES oOT. ICC-ES REPORT At
DESCRIPTION OF WORK l Z
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 ca et. I have read th escriptio of Work and verify it is accuiste. I ee to comp) 'th all applicable local
ordinances and state laws relating to but ng n ction. I riz resentativ s of Cupertino tc enter the ab Ied prope ;for inspection purposes.
Signature of Applicant/Agent: Date: /
..'?ice ''" YaY- "p .� �. �_1t• .slscii _ lwi
SUPPLEMEINFORMATION REQ
_If building is associated with a Home Owner's Association,provide letter P � T�'PE aurJtrc sty '
of approval from HOA. B1rcPn_xtEwOv .
_Provide Planning approval to verify if there any restrictions. ess x= — D PLANNDVG PLA21]tEVIE R' -
se r� q
_Provide copy of Manufacturer's Installation Specifications. 777,
kTxE'nF.P�'
r-f - j' yW ��-5'F....1y1•T.-
Provide signed copy of Cupertino's Tear-Off Policy. = ; Q>oTSEx i
ReroofApp_2011.doc revised O3/O2/11