11070065 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11033 CANYON VISTA DR CONTRACTOR:SORENSON&ASSOCIATES PERMIT NO: 11070065
ROOFING INC
OWNER'S NAME: FAUST R S AND MARILYN J PO BOX 786 DATE ISSUED:07/15/2011
R'S PHONE: 4082551989 BRENTWOOD,CA 94513 PHONE NO:(925)626-7682
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class `2,9 Lic.# ItK3ttt) MECH r RESIDENTIAL r COMMERCIAL
Contractor Q �,SSUC I ' -e Date
� �" JOB DESCRIPTION:REROOF,24 SQ,INSTALL ONE OVERLAY OF SINGLE PLY
I hereby affirm t1a4 irk Ifnsed�i nier the provisions of Chapter 9 DURO LAST OVER EXISTING BUR ROOF
(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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$12115
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:35628042.00 Occupancy Type:
APPLICANT CERTIFICATION
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-po' :eullationi s per the Cupertino Municipal Code,Section
9.18. i Issued by: Date:
Signature a Date
L OWNER--BMILDTR DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first n an inspection,I agree to remove all new materials for
the following two reasons: inspection.
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, Signature of Ap�tiean' Date
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
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 JVn r t:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date: A
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of stork's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
i• ' rnify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
grmuting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
CITY OF CUPERTINO
3 ITEMS OF 12 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN 35628042 . 00
DATE ISSUED. . . . . . . : 07/15/2011
RECEIPT #. . . . . . . . . : BS000014051
REFERENCE ID # . . . : 11070065
SITE ADDRESS . . . . . : 11033 CANYON VISTA DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : FAUST R S AND MARILYN J
ADDRESS 11033 CANYON VISTA DR
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5400
RECEIVED FROM . . . . : SORENSON & ASSOCIAT
CONTRACTOR . . . . . . . : LARRY SORENSON & HILARIO BASTI LIC # 32054
COMPANY . . . . . . . . . . : SORENSON & ASSOCIATES ROOFING
ADDRESS PO BOX 786
CITY/STATE/ZIP . . . : BRENTWOOD, CA 94513
TELEPHONE . . . . . . . . : (925) 626-7682
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 12, 115 .00 1. 00 0. 00 1 .00 0 .00
1BSEISMICR VALUATION 12, 115 .00 1.21 0 . 00 1 .21 0. 00
1REROOFRES SQ FEET 24 .00 336 . 00 0. 00 336 .00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 338.21 0. 00 338 .21 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 \`\0
(408)777-3228• FAX(408)777-3333 •building a�cupertino.org \VJ
CUPERTINO
PROJECT ADDRESS APN 0[
OWNER NAME PHONE E-MAIL
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STREET ADDRESS CITY, STATE,ZIP FAX
1
APPLICANT NAME PHONE E-MAIL
GREET ADDRESS CITY,STATE, ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAMELICENSE NUMBER LICENSE TYPE BUS.LIC.#
cL(a
COMPANY NAME -ri7L E-MAIL FAX
C� C�
STREET ADDRESS CITY,STATE,ZIP PHONE
CIU-, s
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF FD or Duplex ❑ Multi-Family ROOF AREA: VALUATION:
STRUCTURE: ❑ Commercial 14 C� IF t
EXISTING ROOF TYPE: BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY)
REMOVE/REPLACE ❑YESIF NO, PLYWOOD Z%' ❑ PLYWD ❑ OSB PITCH: ROOF
�'1v0 #LAYERS: THICKNESS: ❑ 5/8" TYPE: CDX V '12 CLASS: A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER P ICC-ES REPORT#
DESCRIPTION OF WORK: ,
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 b ']ding construction.Taut !.ze representatives of Cupertino tc enter thef above-identified property for inspection purposes.
Signature of Applicant/ Date: ( � `
/� 2 € 7FFTCE £E O
✓// SUPPLEMENTAL INFORMATION REQUIRED
_If bulldmg is associated with a Home Owner's Association,provide letter �' N c> CX, P,M i "�' IZN,G sI rP r
of approval from HOA. 1;�,pvFGx'I1 CpIjN�LRs BUIIDINGPLANREVIEW °
—Provide Planning approval to verify if there any restrictions. �] ExPlss PraNNpvc PLANREVIEw
r s
_Provide copy of Manufacturer's Installation Specifications. �TANnr,��I
Provide signed copy of Cupertino's Tear-Off Policy. _ C1 OTHER
ReroofApp_2011.d6c revised 03/02/11