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11050269 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10010 MOSSY OAK CT CONTRACTOR:DRAEGER PERMIT NO: 11050269 CONSTRUCTION INC OWNER'S NAME: THAKURIA DIPANKAR AND JYOTI 605 COMMERCIAL ST DATE ISSUED:08/22/2011 TRUSTEE OWNER'S PHONE: SAN.IOSE,CA 95112 PHONE NO:(408)536-0420 ❑ LICENSED CONTRACTOR'S Dr DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Cl J Lic.# (7 ('7r MECH I- RESIDENTIAL I- COMMERCIAL Contracto -�� Date �� V JOB DESCRIPTION: RE-ROOF 9.5 SQ-1/2"PLYWOOD,TPO OVERLAY WITH 2 1 hereby affirm tha 1 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 ofthe 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 I' r which this APN Number:34232104.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION YK 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 R M LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, n // costs,and expenses which may accrue against said City in consequence of the Issued by: Date: granting of this permit. Additio try, the applicant understands and will comply with all non-point source re ations per the C ertino Municipal Cod Section 9.18. �? RE-ROOFS: Signature Date S l� All roofs shall be inspected prior to any roof g material being installed. If a roof is installed without first obtaining an insp on,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Date: -�� l I hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature of Applicant: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I,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) HAZARDOUS MATERIALS DISCLOSURE 1.as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). 1 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 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 of the 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 Co e,Chapter 9.12 and the Health&Safety Code,Se ions 25505,25533,and 2 4. 1 have and will maintain Worker's Compensation Insurance,as provided for by f C Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized age + ri /f� Date: Z permit is issued. I certify that in the performance of the work for which this permit is issued,1 shall not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY Compensation laws of California. If,after making this certificate of exemption,I 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 work's for which this permit is issued(Sec.3097,Civ C.) forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Name APPLICANT CERTIFICATION Lender's Address I certify 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. 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 9 18, Signature Date CITY OF CUPERTINO 3 ITEMS OF 19 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 34232104 . 00 DATE ISSUED. . . . . . . : 08/22/2011 RECEIPT # . . . . . . . . . BS000014512 REFERENCE ID # . . . 11050269 SITE ADDRESS . . . . . : 10010 MOSSY OAK CT SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER THAKURIA DIPANKAR AND JYOTI TR ADDRESS . . . . . . . . . . : 10010 MOSSY OAK CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 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 9 . 00 126 . 00 0 . 00 126 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 127 .50 0 . 00 127 . 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 1 �� CuPERTtN a (408)777-3228• FAX(408)777-3333 •buildinafdDcuDei ino.org \ 00k O pnnisrr1rr,v.cc 55 1 d G APN �y L 1 r—a4- -� /n�a `T cT 1 V 1 OWNP1tNAME, .I 1 h(��.��I a-, -c)l pV r' ► ';nom MAIL wL► STREET ADDRRc.c 1 FAX J 7 l`� l (�•o C u- � � - PHONE E-MAIL � 4 / FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ¢CONTRACTOR ❑CONTRACTOR AGENT ❑ AR (CHITECT ❑ENamz;tc ❑ DE,II opER ❑TENANT C CTQRNAME ;IE-MAIL NUMB 1EI�'$ TYPE BUS.LIC.# G( — `�-�� r a �y� Gc FAX coMP A7�(J�� {Y l�U FT/G7,0 STATE= C 4 z y ARCEETECT)ENGINEER NAhS , LICENSE NJ BUS.LIC.# COMPANY NAME E-MAIL FAX STREET'ADDRESS C .STATE:ZIP PHONE SFD or Duplex E3 Multi-Family ROOF��`�q . /0- "! - .[, "•"'°TT^" USE OF STRUCTURE: Elm Commercial AV !/Pj EXM-NG ROOF TYPE: UILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY) REMOVE/REPLACE ❑YES IF NO. PLYWOOD 'h" ❑ PLYWD ❑ OSB PITCH ROOF D #LAYERS: THICKNESS: ❑ 518" TYPE: COX '12 CLASS: A ,.�( ICC-ES REPORT� PROPOSED ROOF TYPE: 11BMT-UPROOF ❑ASPHAHI LT SNGLES ElWODD SHAKES El WOOD SHINGLES �OTrIER DESCRIPTION OF WORK/ • U .2Y �'l� l6 By my signature below,I certify to each of the followi : I the property owner thdrized agent to act on the property owner's behalf. I have read this application and the information I have provided is c c have read thG"Des ' tion o Worl:and verify it is accurate. I e to c y with all applicable local ordinances and state laws relating to building c n. I a orize n enter'Yes f Cupertino tc enter the above-) tified pro/.rt for inspection purposes. Signature of Applicant/Agent: Date: Z G SUPPLE ALORMATION REQ _ - If building is associated vrith a Home Owner's Association,provide letter i_ Pr;a nr c'r �ttozl�NG sig F { =, of approval from HOA. E o«Rxaoi�I. �Bv>znaiGaN REv»w~ - . cArE�`.a �-� a "` �•..:.,kap^ = it _Provide Planning approval to verify if there any restrictions. T. J. i�ss ' Pre.. *miGPLArtvlEw Prov e copy of Manufacturer's Installation Specifications. ra y , , tx j `t7 r rRFD Provide signed copy of Cupertino's Tear-Off Policy. - - ReroofApp 2011.doc revised 03/02/11