11050253 CITY OF CUPERTINO BUILDING PERMIT
Bt`H.DING ADDRESS: 10012 MOSSY OAK CT CONTRACTOR: DRAEGER PERMIT NO: 11050253
CONSTRUCTION INC
OWNER'S NAME: MOHR JANET M 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— 1°_
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# F_ ( r—
MECH RESIDENTIAL COMMERCIAL
Contractor 6e15 Date_, I
hJOB DESCRIPTION: RF,-ROOF 10.8 SQ-1/2"PLYWOOD,TPO OVERLAY WIT[{2
ereby 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.
I 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:34232105.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION I V6�
I certify that 1 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 F�LOM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which rn a rue against said City in consequence of the �n,�
eranting of this permit. iti ally,the applicant understands and will comply Issued by: //� Date:
with all non-point sour re latipns per Cu ertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature_ Date Z5 All roofs shall be inspected prior to any to n material being installed. If a roof is
installed without first obtaining a4insp ton,lagree toremove all new materials or
inspection.
❑ Ow'NER-BUILDER DECLARATIONSignature of ApplicantI hereby affirm that 1 am exempt from the Contractor's License Law for one of
the follo"ing two reasons: AL1,ROO OVEO BE CLASS"A"OR BETTER
L as owncr 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)
1,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 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 ofthe Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Secti ns 25505,25533,andW2551,Section 3700 ofthe Labor Code,for the performance of the work for which this - G_ t
permit is issued. Owner or authorized agent• Date:_
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 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
to thwith 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 certiI\ 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
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.
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
Q I8
Signature Date
CITY OF CUPERTINO
3 ITEMS OF 12 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN 34232105 . 00
DATE ISSUED. . . . . . . : 08/22/2011
RECEIPT # . . . . . . . . . BS000014510
REFERENCE ID # . . . : 11050253
SITE ADDRESS . . . . . : 10012 MOSSY OAK CT
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER MOHR JANET M
ADDRESS 10012 MOSSY OAK CT
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-5615
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 11 . 00 154 . 00 0 . 00 154 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 155 . 50 0 . 00 155 . 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 950143255
(408)777-3228• FAX(408)777-3333 •building a�cupertino.org
CUPERTINa
/ob�2 t t v 150253
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❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT R�CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
C1 R NAMELl L -� E BUS.LIC.
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COMPANY NAME E-MAIL FAX
STR=ADDRESS CITY,STATE,ZIP P
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USE OF SFD or Duplex E] Multi-Family ROOF_AREA-
AREA-
STRUCTURE: 13❑ Commercial '`� " 5
EXISTING ROOF TYPE: UILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY)
REMOVE/REPLACE ❑YES IF NO, PLYWOOD ;Rr h" ❑ PLYWD ❑ OSB PITCH: ROOF
O #LAYERS: THICKNESS: ❑ 5/8" TYPE: X ,,( '12 CLASS: A
PROPOSED ROOF TYPE: 13BUILT-UPROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES p OTHER ICC-ES REPORT#
DESCRIPTION OF WORK: /
By my signature below,I certify to each of the followi : I the property owner thorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is c e have read the Des tion o Work and verify it is accurate. I ee to c y with all applicable local
ordinances and state laws relating to building c n. I au orize entatives f Cupertino tc enter the above-id tified pro/ for inspection purposes.
Signature of Applicant/Agent: Date: G
SUPPLEMEAL ORMATION REQ r
_If building is associated with a Home Owner's Association,provide letter
of approval from HOA. s r�rF cox j BTnS
arG 1e1GnN RE�7ER
_ -
_Provide Planning approval to verify if there any restrictions. Q
-E2�R'E`SS _ � - ❑ P,I.A2INING PLeFNREVIEW _ -
;.
Prov-we copy of Manufacturer's Installation Specifications. ?
_Provide signed copy of Cupertino's Tear-Off Policy. ❑xortt "
ReroofApp_2011.d6c revised 03/02/11