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11050289 CITY OF CUPERTINO BUILDING PERMIT B1 ILDING ADDRESS: 22651 QUEENS OAK CT CONTRACTOR:DRAEGER PERMIT NO: 11050289 CONSTRUCTION INC OWNER'S NAME: BEATTIE CAROL T ET AL 605 COMMERCIAL ST DATE ISSUED:08/22/2011 ONVNER'S PHONE: SAN .LOSE, CA 95112 PHONE NO:(408)536-0420 ❑ LICENSED CONTRACTOR'S DECLARATION I- F BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class -- Lic.# ) MECH RESIDENTIAL COMMERCIAL Contractor ` Date � `� l I hereby affirm th t 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RE-ROOF 9.3 SQ-1/2"PLYWOOD,TPO 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. 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 of the Labor Code,for the performance of the work foprXwhich his APN Number:34232061.00 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 DMOM OM 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 granting of this permit. Additionally, ie applicant understands and will comply Issued by: G Date: with all non-point source regulat s er the Cupertino Municipal Code,Section 9.18. 7 RE-ROOFS: Signature Date l G f All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an ins n,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applic Date: 2 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF ERINGS TOE 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). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will 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 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 ions 25505,25533,and 25 . Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agenK- VZ cS?k: Date: 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 Compensation laws of California. If,after making this certificate of exemption,1 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 18 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 34232061 . 00 DATE ISSUED. . . . . . . : 08/22/2011 RECEIPT #. . . . . . . . . : BS000014521 REFERENCE ID # . . . : 11050289 SITE ADDRESS . . . . . : 22651 QUEENS OAK CT SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : BEATTIE CAROL T ET AL ADDRESS . . . . . . . . . . : 22670 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 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 (408)777-3228- FAX(408)777-3333 •buildinge-cupertino.org CUPERTtNO 22[P5I G �2 PD 11it!`T ATT9�CC lX�/��✓ O,+K C-4-% APN# -4:2_3f - t-v 3 - �� -�? - OW" .rT Ile— P457,1, ST?L TADDRESSO f rv, STATE F" ^ ` _FAX AP CANT N PHONE a (�Z E-MAIL Irl STREEDRF,$S 1�n P G( S f STATE, ZIP 7_ FAX ElOWNER EIOWNER-BUILDER 13OWNER(AGENTCONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT C CT(�R N LI NUMB LIfg_t TYPE BUS.LIC,# �l( u 5 E-MAIL9C FAX STREET,/ypffD l V (/(/(QV ,(`Ir/lV C STATE CIA 12— �y / ARCHTTECT/ENGINM EER NAE LICENSE L- BUS.LIC.# COMPANY NAME E-MAIL FAX SIR=ADDRESS CITY,STATE,ZIP PHONE USE OF FD or Duplex ❑ Multi-Family ROOF VALUATION: nt G�� STRUCTURE: ❑ Commercial I�/ I (c EXISTING ROOF TYPE: UILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY) REMOVE/REPLACE ❑YES IF NO, PLYWOOD fiZ'h" ElPLYWD ❑ OSB PITCH: ROOF 5eNO #LAYERS: THICKNESS: ❑ 5/8" TYPE: CDX '12 CLASS: A PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES �90THER ICC-ES REPORT# DESCRIPTION OF WORK-- By ORK:By my signature below,I certify to each of th/follo g: I the property owner au sized agent to act on the property owner's be . I have read this application and the information I have providt have rea�3 the Desc' tion of ort:and verify it is accurate. I ee to co y with all applicable local ordinances and state laws relating to buildingn. I a rize pres tatives o Cupertino tc enter thea tifled p err for inspection purposes. Signature of Applicant/Agent Date: �� SUPPLEMENTAL ORMATION REQUIRED ',3 irk c£,m ,ns HE _If building is associated with a Home Owner's Association,provide letter of approval from HOA. Y"pxp> � p PIAN itsR, Provide Planning approval to verify if there any restrictions. n LII EXPSS :Pr�7l�INA'G PFaIN]2ESyIEW _Provide copy of Manufacturer's Installation Specifications. F nm �_ . .. _vProvide signed copy of Cupertino's Tear-Off Policy. _ 4 ❑ spT y €Y - i ReroofApp 2011.doc revised 03/02111