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11080100
CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20170 PACIFICA DR CONTRACTOR:DANCE BUILDERS PERMIT NO: 11080100 OWNER'S NAME: HSU THOMAS K AND MING-TA S TRU 4939 OCCIDENTAL RD DATE ISSUED:08/12/2011 ''NER'S PHONE: 4085181817 SANTA ROSA,CA 95401 PHONE NO:(707)546-0802 L LICENSED CONTRACTOR'S DECLARATION Q �* BUILDING PERMIT INFO: BLDG� ELECT PLUMB� License Class 1✓ Lic.# c�coib 7i MECH RESIDENTIAL COMMERCIAL Contractor— AIMiC5e R4 " Date_tj4Z I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REROOF,14 SQ,REMOVE EXISTING SHAKE,INSTALL (commencing with Section 7000)of Division 3 of the Business&Professions NEW Code and that my license is in full force and effect. 1/2"PLYWOOD,REPLACE WITH NEW 30 Y FELT&40 Y COMP SHINGLES 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. I 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 permit is issued. Sq.Ft Floor Area: Valuation:$7000 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:36928019.00 Occupancy Type: 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, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. SignatureDate Issued by "` –— Date J-72. OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,1 shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. become subject to the Worker's Compensation provisions of the Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner horized a en —e4, 11/1 Vk Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the Lender's Address .ing of this permit.Additionally,the applicant understands and will comply ,,Nan all non-point source regulations per the Cupertino Municipal Code,Section 9.18. ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: TraciC COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 36928019 . 00 DATE ISSUED. . . . . . . : 08/12/2011 RECEIPT #. . . . . . . . . : BS000014419 REFERENCE ID # . . . : 11080100 SITE ADDRESS . . . . . : 20170 PACIFICA DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . : OWNER . . . . . . . . . . . . : HSU THOMAS K AND MING-TA S TRU ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : SAN JOSE CA, 95133-1527 RECEIVED FROM . . . . : DANCE BUILDERS ENTE CONTRACTOR . . . . . . . : MAURICE C DANCE LIC # 31020 COMPANY DANCE BUILDERS ADDRESS 4939 OCCIDENTAL RD CITY/STATE/ZIP . . . : SANTA ROSA, CA 95401 TELEPHONE . . . . . . . . : (707) 546-0802 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 7, 000. 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 7, 000 . 00 0 .70 0 . 00 0 . 70 0 .00 1BUSLIC FLAT RATE 1 . 00 115 . 00 0 . 00 115 . 00 0 .00 1REROOFRES SQ FEET 14 . 00 196 . 00 0 . 00 196 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 312 .70 0. 00 312 . 70 0 .00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 312 .70 4470 --------------- TOTAL RECEIPT 312 .70 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 00 REROOF PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228• FAX(408)777-3333 • building(cDcupertino.oro PROJECT ADDRESS ©110 APN# ;J3 0 1 OWNERNAME , ([J.0 PHONE5194 fP71 E-MAIL STREET ADDRESS ^ n�/ CITY TATE ZIP �� CA FA7( APPLICANT NAME ( A r PHONE D-7 7-2-49^� EMAIL f C })�, � s STREET ADDRESS L \L7,3 11 0C C } CITY,STATE, ZIP FA ( Vy� ElOWNER C1 OWNER-BUILDER (❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CO CTOR NA2v1F LICENSE LICENS E BUS.LIC.# COMPANY NAME �A E-MAIL FAX STREET ADDRESS11439 �� TTY,STA tijUL �X—pc�k p !` PHONE 07 5Y r ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC.# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE of SFD or Duplex ❑ Multi-Family ROOF AREA: !,` VALUATION: STRUCTURE: ❑ Commercial ( /Oo P Sop EXISTING ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES XW0, OD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY) REMOVE/REPLACE YES IF NO, PLYWOOD h" ElPLYWD 13 OSB PTITCH ROOF ❑ NO #LAYERS: THICKNESS: 135/8" TYPE: ElCDX 12 CLASS: PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT# DESCRIPTION OF WORK kWA--<_ 0 re-vs(OLCIE11 LO Ll"jr +- ti, w�w1i� By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. ve read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buil ing constructio I uthorize representatives of Cupertino tc enter the above a ified pr pert,••for inspection purposes. Signature of Applicant/Agent: Date: Z SUPPLEMENTAL INFORMATION REQUIRED ; r If building is associated with a Home Owner's Association,provide letter of approval from HOA. i _ px� BtG�3AatxEvrJr~w Provide Planning approval to verify if there any restrictions. ss - _Provide copy of Manufacturer's Installation Specifications. ZF q "s. T - _Provide signed copy of Cupertino's Tear-Off Policy. � •-zo - - a ReroofApp_2011.doc revised 03/02/11 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CU PERTI NO Fax: 408-777-3333 CONTRACTOR / SUBCONTRACTOR LIST JOB ADDRESS: A C PERMIT# z a �d OWNER'S NAME: ,v _ S LZ PHONE# -70'? Z Zg 5 7 GENERAL CONTRACTOR: BUSINESS LICENSE# 50(00 ADDRESS: ® VZ4CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTO HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: — Z- Signature Dat Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/Carpeting Linoleum /Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting /Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile (2 Ow er/Contractor Signature Dat