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11050256 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10042 MOSSY OAK CT CONTRACTOR:DRAEGER PERMIT NO: 11050256 CONSTRUCTION INC ON1'NER'S NAME: JANET ESAKENAZI 605 COMMERCIAL ST DATE ISSUED:08/22/2011 OWNER'S PHONE: SAN JOSE, CA 95112 PHONE NO:(408)536-0420 ❑ LICENSED CONTRACTOR'S DECLARATION r BUILDING PERMIT INFO: BLDG ELECT PLUMB; License Class�� Lic.# 01Z F_- MECH RESIDENTIAL COMMERCIAL Contractor l � '�.-I I/f' �/� Datenwt� JOB DESCRIPTION: RL ROOF 10.8 SQ- 1/2"PLYWOOD,TPO OVERLAY WITI1 2 I hereby affirm that am licensed under the provisions of Chapter 9 LAYER IR-10 BARRIER (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 1 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:34232108.00 Occupancy Type: permit is issued. 0&7 .APPLICANT CERTIFICATION 1 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 INSPECTI N. indemnity and keep harmless the Cit of Cupertino against liabilities,judgments, costs_and expenses which may, c e against said City in consequence of the �� granting of this permit. Add orally,the a plicant understands and will comply Issued by: l Date: \kith all non-point source gylations the Cupertino Municipal Code,Section 9.18 t i RF,- FS: Signature �� Date �S �� All roofs shall be inspected prior to a oofing material being installed. If a roof is installed without first obtaining an ' speution,I to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION 2 . Signature of Applicant `' Date: I hereby affirm that I 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 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 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,See 'ons 25505,25533,and 2553 ! Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: ' Date: permit is issued. I certitN 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 ofexemption,t 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 certifi 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 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. Signature _ —Date CITY OF CUPERTINO 3 ITEMS OF 12 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 34232108 . 00 DATE ISSUED. . . . . . . : 08/22/2011 RECEIPT #. . . . . . • . . : BS000014510 REFERENCE ID # . . . : 11050256 SITE ADDRESS . . . . . : 10042 MOSSY OAK CT SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . : OWNER . . . . . . . . . . . . : JANET ESAKENAZI ADDRESS . . . . . . . . . . : 10042 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 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 622 . 00 0753 --------------- TOTAL RECEIPT 622 . 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(40 8)777-3333 •building cupertino.org CUPERTlNO ^ n�J_"`p Pv nTC!`T 55 z� GT_. APN# O .'^'-- PHO/ EMAIL _ SrREEI�ADDRESS O / rY, STA ^ ` FAX LO AP C ! PHONE E-MAIL. STREET-40DRF,$ '�n PV`- � / >STATE. ZIP � 71 FAX . El OWNER El OWNER-BU4C ILDER ❑ OWNER AGENT QONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT COXTFLACTQRNAE C-1C-1 LI NUMB To—i E BUS.LIC.# u COMP16LX ►�/G `o / STREETT,/y�8((�/l�� �yV E-MAIL FAX QY `�`� /i - STATE N„ r� ARCHITHCT/ENGINEER NAME l LICENSE Z BUS.LIC.# COMPANY NAM" E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or Duplex ❑ Multi-Family ROF 4REA a rre nor. / ?j�0' /61-x ,/ ( t STRUCTURE: ❑ Commercial Aw 1141 �' ��V �" S EXISTING ROOF TYPE: UILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY) REMOVE/REPLACE ❑YES IF NO, PLYWOOD ;W e ❑ PLYWD El OSB PITCH FCLASS O #LAYERS: THICKNESS: ❑ 5/8" TYPE: �CDX -'12 A PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES OTHER ICC-ES REPORT# DESCRIPTION OF WORK ! :W0 oVQ,-- av �C 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 ect have read the Des ' tion o Work and verify it is accurate.�Ll to c ly with all applicably local ordinances and state laws relating to building c n. I a orize re entatives f Cupertino tc enter the above-i ro ..t for inspection purposes. Signature of Applicant/Agent Date: L SUPPLEMEAL ORMATION REQ � �r�r.�.3..ar.� a,'�'-rw;:ar�_,,x-C+�•ai .KF ru,�-•m'�Y•k�r `= t+^ a S'4i-_:'_ —If building is associated with a Home Owner's Association,provide letterrI rat ecicxYPE.� -£ ourG sL� ; �- of approval from HOA. ov�Reoinv % $I1II.G>'funN REvv" - IL Provide Planning approval to verify If there any restrictions. II x ss © PLALVNII�G PLAN. EVIE.W tet!. � vim^Prov-we copy of Manufacturer's Installation Specifications. ❑ ❑ Ftx nFPT Provide sided copy of Cupertino's Tear-Off Policy. _ ❑ 'OTHER. - s_ ReroofApp_2011.d6c revised 03/02/11