11050285 CITY OF CUPERTINO BUILDING PERMIT
BUILDING.ADDRESS: 22631 QUEENS OAK CT CONTRACTOR: DRAEGER PERMIT NO: 11050285
CONSTRUCTION INC
OWNER'S NAME: FISHER WILLIAM H 2 AND MARY C 605 COMMERCIAL ST DATE ISSUED:08/22/2011
OWNER'S PHONE: SAN JOSE, CA 95112 PHONE NO:(408)536-0420
❑ LICENSED CONTRACTOR'S DECLARATIONr—
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Cla Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor. Date G �/
JOB DESCRIPTION: RE-ROOF 9.3 SQ-1/2"PLYWOOD,TPO OVERLAY WITH 2
1 hereby affirm that 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.
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:$375
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 ofthe Labor Code.for the performance of the wor4fqr which this APN Number:34232057.00 Occupancy Type:
permit is issued. P_ Y�
APPLICANTCERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY MLAST CALLED INSPE TION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue gamst said City in consequence of the
granting of this permit. Additio ,the applicant understands and will comply Issued by: Date:
with all non-point source r$peration er the Cupertino Municipal Code,Section
9.18. '
/ 1 RE-ROOFS:
Signatur Date 2 All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an ins tion,I agree to remove all new materials for
inspection.
❑
OWNER-BUILDER DECLARATION
Signature of Applic / Date:
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)
I,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. I 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 self-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 I
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,Sec 'ons 25505,25533,an 25
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agenh __ 'J / Date:� �l
permit is issued.
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
CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,1
become subject to the Worker's Compensation provisions of the Labor Code,1 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 certi(N that 1 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 18 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 34232057 . 00
DATE ISSUED. . . . . . . : 08/22/2011
RECEIPT #• . . . . . . . • : BS000014521
REFERENCE ID # . . . : 11050285
SITE ADDRESS . . . . . : 22631 QUEENS OAK CT
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : FISHER WILLIAM H 2 AND MARY C
ADDRESS . . . . . . . . . . : 22631 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 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
GUPERTiNO
(408)777-3228• FAX(408)777-3333 •building al -cupertino.org
/
2ntp 30 _ 11 05 0 5
pvnrrrr ennvrec au-e-00-5 APN#
OWr—„ . / MQ r F—i s /' P _ (T zS=�l�� E-MAM
STREE-ADDRESS O ` CITY. STATE ^ ( FAX
AP CANT I� `,(f PHONE C E-MAIL
STREE D S4 C STATE, ZIP Z FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
C CT(�R N LICVf NUMB — E BUS.LIC.#
E-MAIL FAX
"'18r
TREET, 8 � Qr r�o1 l C STATE N - /
ARCHITECT/ENGINEER NAME LICENSE BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP HONE
USE OF FD or Duplex ❑ Multi-Family Roo EA: VALUATION:
STRUCTURE: ❑ Commercial ' S 9 K , 1 b`i' �j� 1 V
EXISTING ROOF TYPE: UILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES:�On�(SPECIFY)
REMOVE/REPLACE ❑YES IF NO, PLYWOOD g'h" ❑ PLYWD El PITCH: =CLASS
O #LAYERS: THICKNESS: ❑ 5/8" TYPE: X '12
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES OTHER ICC-ES REPORT#
DESCRIPTION OF WORK:
By my signature below,I certify to each of the folio g: I the property owne r au rized agent to act on the properly owner's be I have read this
application and the information I have provided is rrect have reals the Desc ' tion of ork and verify it is accurate. I ee to co y with all applicable local
ordinances and state laws relating to building c tru nn. I au rite r pres tatives o Cupertino tc enter the ae '�fied p e.,i r inspection purposes.
Signature of Applicant/Agent: Date: S G
SUPPLEMENTAL ORMATION REQUIRED
_If building is associated with a Home Owner's Association,provide letter Pte ' _ oul�Nsi . " �3
of approval from HOA. 10. V
} RV -' BIJILDhiG4+AN.IrE �R'
-.' .
.'' ��3Y'."E - '33a+rM'a3i'1 ^c E "en''k`_- "�+'.'•.{..
_Provide Planning approval to verify if there any restrictions. SSSS ' "
3E
Z- �'�LANNAfG PLA1�t �W
221E
Provide copy of Manufacturer's Installation Specifications.
� Z to . SfvFY S
t rovide signed copy of Cupertino's Tear-Off Policy. 4 ❑ t r
ReroofApp_2011.doc revised 03/02111