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11050284 CITY OF CUPERTINO BUILDING PERMIT BUILDING,ADDRESS: 22681 QUEENS OAK CT CONTRACTOR: DRAEGER PERMIT NO: 11050284 CONSTRUCTION INC OWNER'S NAME: VIVEK ASHARMA 605 COMMERCIAL ST DATE ISSUED:08/22/2011 OWNER'S PHONE: SAN JOSE, CA 95112 PHONE NO:(408)536-0420 ❑ LICENSED CONT'RACTOR'S DECLARATION � C� r— BUILDING PF,RMIT'INFO: BLDG ELECT PLUMB License Class Lic.# r MF,CH RESIDENTIAL COMMERCIAL Contractor 1e, 66 Date 1 hereby affirm that am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RE-ROOF 10.4 SQ-1/2"PLYWOOD,'FPO OVERLAY WITH 2 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 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 ifigr which this APN Number:34232067.00 Occupancy Type: permit is issued. 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 DAY R M LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the -ranting of this permit. Additionally, pplicant understands and will comply Issued by: G Date: with all non-point source regulatio pe the Cupe Municipal Code,Section RE-ROOFS: Signature Date` 2 l/ All roofs shall be inspected prior to any roofi aterial being installed. If a roof is installed without first obtaining 4inspe ,Uagree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: ate: Z 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 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) 1.as owner of the property,am exclusively 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 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 sell'insure for Worker's material. Additionally,should 1 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 Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Se ons 25505,25 33,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this �� Date: 2 permit is issued. Owner or authorized agen (/ 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 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 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 15 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 34232067 . 00 DATE ISSUED. . . . . . . : 08/22/2011 RECEIPT # . . . . . . • . • : BS000014524 REFERENCE ID # . . . : 11050284 SITE ADDRESS . . . . . : 22681 QUEENS OAK CT SUBDIVISION . . . . . . : CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . : OWNER . . . . . . . . . . . . : VIVEK ASHARMA ADDRESS . . . . . . . . . . : 22681 QUEENS OAK CT CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5616 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 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 707 . 50 0753 --------------- TOTAL RECEIPT 707 . 50 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 • buildinp(a)cupertino.org VZ10's1 110 50a Pvnrcrr.nnnrcc =0 E-MAIL STREET_ADDRESS O�. / �rI Y, STATE ^ ` FAX AP CANT N P l`(f L ;HONE STRa�D S 1 AA � S� ,STATE,ZIP � ?' FAX ❑ OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT �ONTRACI'OR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT COCT(?R NAME LI NUMB LI�EN$� E BUS.LIC.# �( u — ` 5 E-MAIL FAX STR._IV ct 04MIOY t6l, 7 A C-`'` 2012 ARCHITECT/ENGINEER NAME LUI ENUBUS.LIC.# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF r—SFD or Duplex ❑ Multi-Family Pop,F Ag�A: VALVATTnN• �,�i STRUCTURE: ❑ Commercial (/ '7 50 '� ,`f )v T a bb S EXISTING ROOF TYPE: UILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY) REMOVE/REPLACE ❑YEs IF NO, PLYWOOD g'b" ElPLYWD El OSB PITCH: ROOF 0 #LAYERS: THICKNESS: ❑ 5/8" TYPE: Ea CDX — —:12 CLASS: A PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES 0o711ER ICC-ES REPORT# DESCRIPTION OF WORK r Ol�r/�. l 2 Leg By my signature below,I certify to each of the foil 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 verify it is accurate. I gree to com with all applicable local ordinances and state laws relating to build' tructi . I auth a represen 'ves of Cupertino tc enter the atove-' 7tified pro /`or inspection purposes. Signature of Applicant/Agent Date:S G v SUPPLEME ORMATION REQ D _If buildings associated with a Home Owners Association, - �L ' n,Provide letter �-� ouWcSLTp of approval from HOA. -OVEM7t LF �� * G. w _Provide Planning approval to verify if there any restrictions. - s ,4_ 'F,30'RESB Y ,o;_ PL7l7�TfRiTGYLANREVIEA' _Prov' copy of Manufacturer's Installation Specifications. " �. n, � , , a � r P✓ rovide signed copy of Cupertino's Tear-Off Policy. z _ _ ❑ p THFi Reroof4pp_2011.doc revised 03/02111