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11050283 CITY OF CUPERTINO BUILDING PERMIT 131 ILDING ADDRESS: 22673 QUEENS OAK CT CONTRACTOR: DRAEGER PERMIT NO: 11050283 CONSTRUCTION INC ON NER'S NAME: CHING WEI CHUN 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)n— Lic.#_ �_��7fs�/& i— 'l � MECH RESIDENTIAL COMMERCIAL Contracto �th, l G��Date l JOB DESCRIPTION: RE-ROOF 10.4 SQ-1/2"PLYWOOD,TPO OVERLAY WITH I hereby affirm 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. 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 ofthe Labor Code,for the performance of the work f hich this APN Number:34232066.00 Occupancy Type: permit is issued. YYY 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 INSPE TION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, nr costs_and expenses which may accrue a st said City in consequence of the46 Jv� granting of this permit. Additional) applicant understands and will comply Issued by: '� Date: with all non-point source regula per the Cu ertmo Municipal Code,Section RE-ROOFS: Signature_ _Date !�5 All roofs shall be inspected prior to any roofi aterial being installed. If a roof is installed without first obtaining an mspec i n, gree to ve all new materials for inspection. ❑ OV1'NER-BUILDER DECLARATION ZI Signature of Applicant Date: l I hereby affirm that 1 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 e.xclusivcly contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE 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 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,Se ions 25505,25533,and 255 Section 3700 of the Labor Code,for the performance of the work for which this rJ G; Owner or authorized agent. 1,// Date: permit is issued. I certifN 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 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 certifj 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 indcnimfj and keep harmless tile fe City oCupertino 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 9 18. Signature _Date CITY OF CUPERTINO 3 ITEMS OF 15 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN 34232066 . 00 DATE ISSUED. . . . . . . : 08/22/2011 RECEIPT #. . . . . . . . . BS000014524 REFERENCE ID # . . . : 11050283 SITE ADDRESS . . . . . : 22673 QUEENS OAK CT SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER CHING WEI CHUN ADDRESS 22673 QUEENS 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 10 . 00 140 . 00 0 . 00 140 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 141 .50 0 . 00 141 .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 CUPERTfNO .(408)777-3228• FAX(408)• 777-3333 • building aacupertino.org 22z(S--3 _C APN# I I05 6E PDlC- �TTDSCC � G O W ln�'— Z?i(e-7 g3 P = E-MAIL STREET ADbAsFAX AP CANT 11 f PHONE (� E MAII tit S D1) e Gt _5 STATE.ZIP ?' FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT �ONTRACrOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT C CT(�R NAME � LI ust NUMB LI EA**$� E BUS.LIC.# CE-2� 9 COMP 60e, V l�V F�U�/7/O E-MAIL FAX v I(/l� L (�. " STR FT,/yT�8 p{l .!'`r/l 7 �A �-" t— / ARC TECT/ENGINEER NAME LICENSE BUS.LIC.# COMPANY NAME E-MAIL FAX STREET ADDRESS CrrY,STATE,ZIP PHONE USE OF -_SFD or Duplex ❑ Multi-Family ROOF Aj�k VACUA,rn>v q 1 STRUCTURE: ❑ Commercial v `I c C`� I ` C` a 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: EZ CDX ,,( 12 CLASS A PROPOSED ROOF TYPE: 11BUILT-UPROOF ❑ASPHALT SHINGLES El WOOD SHAKES El WOOD SHINGLES 9 '071AER ICC-ES REPORT# DESCRIPTION OF WORK: r �i` •e l a O(�P/�. l 2 By my signature below,I certify to each of the foll g: I am the prop r or authorized agent to act on the property owner's be f. I have read this application and the information I have provided' rrect. I have re a Descrip on of Work and v;,Jrify it is accurate. I gree to corn with all applicable local ordinances and state laws relating to build' tructi I auth a represen 'ves of Cupertino to enter the a ove ntified pro /for inspection purposes. Signature of Applicant/Agent: Date: Z v 4 � d4... -.-...- ,'Jy�."r.i1.- �'•-c'"a .gyp SUPPLE ORMATION REQ D �4 coo . _If building is associated with a Home Owner's Association,provide letter oz7ivcLtP of approval from HOA. D o _ 4r BI�ilvcptax xEtw Provide Planning approval to verify if there any restrictions. �1CPRES�6 ��L71-L�i�'GPLAN]tEVIER� Prov: copy of Manufacturer's Installation Specifications. 0--ST'ANDI4BD 'x�-z � Q bEPT'` Provide signed copy of Cupertino's Tear-Off Policy. ReroofApp 2011.doc revised 03/02/11