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11070165 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20920 MCCLELLAN RD CONTRACTOR:SHELTON ROOFING PERMIT NO: 11070165 OWNER'S NAME: RECTOR WARDENS VESTRYMEN OF ST JUDES 1988 LEGHORN ST DATE ISSUED:07/22/2011 OWNER'S PHONE: 4086666834 MOUNTAIN VIEW,CA 94043 PHONE NO:(650)961-7699 G LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL F-1COMMERCIALE] RE ROOF TEAR OFF EXISTING BUILT IJP,REPLACE-,DRYROT 1 (9 License Class ic. AND REPLACE WITH NEW TAR AND GRAVEL ROOF.19 SQS rr ,C" ���L( # �U ��-\ l Contractor i f1L a0,r, '�`� Date I hereby affirm that 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. 1 hereby affirm under penalty of perjury one of the following two declarations: Sq.Ft Floor Area: Valuation:$13480 t 1 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 APN Number:35920028.00 Occupancy Type: performance of the work for which this permit is issued. 2. 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 permit is issued. PERMIT EXPIRES IF WORK IS NOT STARTED APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR I certify that I have read this application and state that the above information is 180 DAYS FROM LAST CALLED INSPECTION. 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 Issued bye__-_,""' Date: 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,the applicant understands and will comply with RE-ROOFS: all non-point source regulations per the Cupertino Municipal Code,Section 9.18.1— All roofs shall be inspected prior to any roofing material being installed. If a roof is `Z, installed without first obtaining an inspection,1 agree to remove all new materials for Signature ��`�'''` Date inspection. 7 Signature of Applicant: ��-�'" �"'"� Date: _ ❑ OWNER-BUILDER DECLARATION by affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER the following two reasons: 1 1,as owner of the property,or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE: compensation,will do the work,and the structure is not intended or offered for sale(Sec.7044,Business&Professions Code) I have read the hazardous materials requirements under Chapter 6.95 of the 2 1,as owner of the property,am exclusively contracting with licensed contractors to California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain construct the project(Sec.7044,Business&Professions Code). compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should 1 store or handle hazardous material. 1 hereby affirm under penalty of perjury one of the following three declarations: Additionally,should 1 use equipment or devices which emit hazardous air 1 1 have and will maintain a Certificate of Consent to self-insure for Worker's contaminants as defined by the Bay Area Air Quality Management District I will Compensation,as provided for by Section 3700 of the Labor Code,for the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&Safety Code,Sections 25.505,25533,and 25534. performance of the work for which this permit is issued. 2 I have and will maintain Worker's Compensation Insurance,as provided for by Ow er or authorized agent: —1ZZ.-k 1 Section 3700 of the Labor Code,for the performance of the work for which this Date: permit is issued. 3 1 certify that in the performance of the work for which this permit is issued,I shall CONSTRUCTION LENDING AGENCY 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 thereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued(Sec.3097,Civ C.) become subject to the Worker's Compensation provisions of the Labor Code,I Lender's Name must forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Address APPLICANT CERTIFICATION ARCHITECT'S DECLARATION I certify that I have read this application and state that the above information is I understand my plans shall be used as public records. 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 Licensed Professional upon the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the gting of this permit.Additionally,the applicant understands and will comply with m-point source regulations per the Cupertino Municipal Code.Section 9.18. Signature Date Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 ELI] Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: 12-6'kZ0 ✓(� 6 6Len a PERMIT# OWNER'S NAME: . e5 L,-«- PHONE# 65 p 0 1 GENERAL CONTRACTOR: She-j�o� BUSINESS LICENSE# ADDRESS: a e4Z-e �oc Sf. 5�; e L_ CITY/ZIPCODE:f �U`cam *Our municipal code requires all businesses working in the city to have a City of Cupertino 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. h 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 Owner/Contractor Signature Date CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: suew COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 35920028 . 00 DATE ISSUED. . . . . . . : 07/22/2011 RECEIPT # . . . . . . . . . : BS000014150 REFERENCE ID # . . . : 11070165 SITE ADDRESS . . . . . : 20920 MCCLELLAN RD SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER RECTOR WARDENS VESTRYMEN OF ST T(.) ((� ADDRESS 20920 MCCLELLAN RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : SHELTON ROOFING CO CONTRACTOR . . . . . . . : WRAY, RICHARD LIC # 20755 COMPANY SHELTON ROOFING ADDRESS . 1988 LEGHORN ST CITY/STATE/ZIP . . . : MOUNTAIN VIEW, CA 94043 TELEPHONE . . . . . . . . : (650) 961-7699 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 13 , 480 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICO VALUATION 13, 480 . 00 2 . 83 0 . 00 2 . 83 0 . 00 1REROOFCOM SQUARES 19 . 00 359 . 00 0 . 00 359 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 362 . 83 0 . 00 362 . 83 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 362 . 83 18482 --------------- TOTAL RECEIPT 362 . 83 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 CUPERTINO (408)777-3228• FAX(408)777-3333•buildingacupertino.org //���/� r PROJECT ADDRESS . �` 2 �( �'f '�-�'1 ��` bAPN# R PHONE >/v� E-MAIL OWNER NAME £ l / x- STREET ADDRESS CLI J? ! rryySTATE,ZIP J FAX APPLICANT NAME C& G7! PHONW �ltr /!f! /� E-MAIL STREET ADDRESS CrrY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR Co CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME t j ! LICENSE NU�MBL��ryp• /y LICENSE TYPE BUS.LIC.# � t COMPANY NAME ` _ / lo tei 4o E M�L�CJ FAX STREET ADDRESS ,5�L ,STA ,ZIP PHONE ,�� t ARCHITECT/ENGWEER NAME (•e G (, f/JJ J LICENSE NUMBER BUS.LIC.# l COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ❑ SFD or Duplex ❑ Multi-Family ROOF AREA: VALUATION: 12, STRUCTURE: f'bnimercia C 1 j • EXISTING ROOF TYPE: O BUILT-UP ROOF ❑ASPHALT S (ro ©LES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY) REMOVE/REPLACE i IF NO, PLYWOOD ❑ w, ❑ PLYWD ❑ OSB PITCH: ROOF ❑NO #LAYERS: S: ❑ vs., TYPE: ❑ CDX '12 ASS: A PROPOSED ROOF TYPE: XBULT-UP ROOF E)ASPHALT SHINGLES ElWOOD SHAKES ❑WOOD SHINGLES ❑O-rHER ICC-ES REPORT# DESCRIPTICel-2 TX q 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 building construction. I authorize representatives of Cupertino to enter the above-identified propemy for inspection purposes. Signature of Applicant/Agent. rI�' �' '� "' Date: d r t SUPPLEMENTAL INFORMATION REQUIRED I _If building is associated with a Home Owner's Association,provide letter F '"+ ousI sL17P of royal from HOA. now _ " approval f i1 R Q N1'Eit` �: -MING�LALZ�.RE%�09 Provide Planning approval to verify if there any restrictions. r � �x —C13� a tn� P>sAar*E_ - � � .-- I �F Provide copy of Manufacturer's Installation Specifications. Provide signed copy of Cupertino's Tear-Off Policy. ReroofApp_201 1.doc revised 03/02/11