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11100196 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 11836 PINE BROOK CT CONTRACTOR:CASTILLO'S ROOFING PERMIT NO: 11100196 OWNER'S NAME: SR1NI POLAVARAPY 1703 CATHAY DR DATE ISSUED: 10/28/2011 "WNER'S PHONE: 4083938137 SAN JOSE,CA 95122 PHONE NO:(408)251-3565 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL _n < `) S" RE-ROOF 18 SQ- TEAR OFF WOOD SHAKE,APPLY 30LB License Class Li,.# FELT,APPLY GAF GRAND CANYON COMP CLASS A Contractof. Date d �� I hereby affir hat I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. 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. Sq.Ft Floor Area: Valuation:$9500 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 APN Number:36655039.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT E S IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITffiN YS 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 M LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, // /l costs,and expenses which may accrue against said City in consequence of the Issued by: Date:/6_Z5_ granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date aY/' All roofs shall be inspected prior to any roofing material berg installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. OWNER-BUILDER DECLARATION ��2 Date: Signature of Applicant: ' 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) I,as owner of the roe y g HAZARDOUS MATERIALS DISCLOSURE property,rty,am exclusively contractin with licensed contractors to 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 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 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, :Section 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized ager 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If,after making this certificate of exemption,I 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, -ists,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. .rnting 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. Sign-- 'JJ 1 C —__._ Date Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: c) PERMIT# OWNER'S NAME: V tiGi PHONE# GENERAL CONTRACTOR: �. % L Cj .S' �� BUSINESS LICENSE# � ADDRESS: CITY/ZIPCODE: �� A-4e b si �� • ��'� *Our municipal code requires all nesses working in the city to have a City of Cupertin business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: -` Signature Date Please check applicable subcontractors and complete the following information: 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 Date caner/Contractor Signature REROOF PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228 • FAX(408)777-3333 • buildinona cupertino.org PR07ECT ADDRESS 1 u� a• � � � � AFN# S S OWNER NAME \ t ) > PHONE E-MAIL STREET ADDRESS STATE ZIP ok ctt�tol FAX -fi ne APPLICANT NAME , O PHO ^7 EMAIL STREET ADDRESS CITY,STATE, ZIP -I-edJo ie AFAX WNER ❑OWNER ❑ OWNER-BUILDER ❑ OAGENT CONTRACTOR 13CONTRACTOR AGENT ❑ ARCHITECT 13❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME ' ( LICENSE NUMEER v�)1 LICENSE TYP + BUS.LIC.# COMPANY NAMEE-MAIL FAX _jai It 12 STREET'ADDRESS CITY,STATE ZIP PHONE �-�l►-,i r(r �G - - . / ARCHITECT/ENGII-IEER NAME LICENSE NUMBER BUS.LIC.# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATES,ZIP PHONE USE OF /SFD or Duplex ❑ Multi-Family ROOF AREA: VALUATION: STRUCTURE: ❑ Commercial EXISTING ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY) REMOVE/REPLACE F, PLYWOOD ❑ h" ❑ PLYWD ❑ OSB PTrCH ROOF ❑ NO YERS: THICKNESS ❑ 5/8" TYPE: ❑ CDX 5 '1Z CLASS: A PROPOSED ROOF TYPE: ❑BUILT-UP ROOF XASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT# DESCRIPTION OF WORK: _�� w o d 5h4,,,o . Anob ' A ctc,=20 W s /I-,Z 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 I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to bis din nstru-t n. I authoD'7ziepresentatives of Cupertino Lc enter the above id ;For inspection purposes. Signature ofApplicanbAgent Date: `(�J SUPPLEMENTAL INF TION REQUIRED IN - _— z - `` � ->• � If building is associated with a Home Owner's Association,provide letter of approval from HOA. _Provide Planning approval to verify if there any restrictions. Provide copy of Manufacturer's Installation Specifications. _Provide signed copy of Cupertino's Tear-Off Policy. �_ i may- •�' '.-L � .,�lw. _� ReroofApp_2011.doc revised 03/02/11