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11070019 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21 190 RAINBOW DR CONTRACTOR:R A PERMIT NO: 11070019 CONSTRUCTION OWNER'S NAME: HWANG BETTY AND LONG-FA 3851 R CHARTER PARK DR DATE ISSUED:07/05/2011 .VNER'S PHONE: 4083688860 SAN JOSE,CA 95136 PHONE NO:(408)559-1877 ❑ LICENSED CONTRACTOR'S DECLARATION I— Ii r— BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class �� Lic.# 3F_ MECH RESIDENTIAL COMMERCIAL Contractor eQT- Date JOB DESCRIPTION: RE-ROOF 30 SQUARES,TEAR OFF OLD SHAKE ROOF I hereby affirm that 1 am licensed under the provisions of Chapter 9 INSTALL ASPHAL f SHINGLF,S OVER EXISTING PLYWOOD (commencing with Section 7000)of Division 3 of the Business&Professions 1/2"CLASS A Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 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 performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$13000 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:36652004.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERM ORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WI I AYS OF IT 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 18 YS FROM LAS CAL ED INSPECTI 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 Issued by: Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date All roofs shall be inspected prio to any roofing material being installed. If a roof is installed without first obtaining n ins p ction,I agree to remove all new materials for inspection. 13OWNER-BUILDERDECLARATION _ I hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALI,2,4VERINGS TO BE CLASS"A"OR BETTER 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, 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 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 1 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,Sections 25 25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this �----- S permit is issued. Owner or authorized agent: Date:_ I certify that in the performance of the work for which this permit is issued,1 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,I 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 1 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 ,i the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION nify 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 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C O P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: PERMIT# OWNER'S NAME: G.ow PHONE# �1� GENERAL CONTRACTOR: - BUSINESS LICENSE# ADDRESS: ` !M./L le CITY/ZIPCODE: *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. I am not using any subcontractors: Signature Date Please check applicable subcontractors and complete the following information: V 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: SylviaM COPY # 1 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 36652004 . 00 DATE ISSUED. . . . . . . : 07/05/2011 RECEIPT # . . . . . . . . . : BS000013961 REFERENCE ID # . . . : 11070019 SITE ADDRESS . . . . . : 21190 RAINBOW DR SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : HWANG BETTY AND LONG-FA ADDRESS . . . . . . . . . . : 21190 RAINBOW DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4978 RECEIVED FROM . . . . : RON ANDREWS CONTRACTOR . . . . . . . : ANDREWS, RON LIC # 21382 COMPANY R A CONSTRUCTION ADDRESS 3851 R CHARTER PARK DR CITY/STATE/ZIP . . . : SAN JOSE, CA 95136 TELEPHONE . . . . . . . . : (408) 559-1877 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 13 , 000 . 00 1 . 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 13 , 000 . 00 1 . 30 0 . 00 1 . 30 0 . 00 1REROOFRES SQ FEET 30 . 00 420 . 00 0 . 00 420 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 422 . 30 0 . 00 422 . 30 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 422 . 30 visa --------------- TOTAL RECEIPT 422 . 30 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 PROJECT ADDRESS f ^fj APN OWNER NA?IM PHONE E-MAIL fi t /� E-,•MAIL /6 AVh STREET ADDRESS CITYTATE ZIP jfa(v FAX i APPLICANT NAME PHO /l/J E-MAIL STREET ADDRESS CITY,ST-A.XE,ZIP / �f T FAX ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT C CT LICENSE NUMBER LICENSE TYPE BUS.LIC.# COMPANY NAME f e01 ' E-MAIL FAX V5, STREET ADDRESS e� � CITY,STATE,ZIP ✓ PHONE 1l• /t ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC.# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF ` SFD or Duplex ❑ Multi-Family ROOF AREA: � VALUATION: STRUCTURE: ❑ Commercial "j V�/li / C/ 00 EXISTING ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES XOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY) —j REMOVE/REPLACE IF N0, PLYWOOD �a ElPLYWD ❑ OSB PITCH ROOF El NO #LAYERS: TT�CKNESS: u 5/B" E: 13CDX 12 CLASS: A PROPOSED ROOF TYPE: ❑BUILT-UP ROOF XP SPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER 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 corr read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildin on authorize representatives of Cupertino tc enter the above-identified property fo inspection purposes. Signature of Applicant/Agent: Date: �_ SUPPLEMENT ORMATION REQUIRED a' . -�.,• 't��L-re.�...:.,��-r.— � „per -:'�:s..-,.+ .F�s��: If building is associated With a Home Owner's Association,provide letter g1'�' � E � ozar¢rc sL24 =. of approval from HOA. pRQ1a �BUII,DING PIiAN-REVIEW Provide Planning approval to verify if there an restrictions. y ..« — g PP �' Y �ao?I�ss ❑ 'Pa:AI�In�It;-PL�TVTuwlEvv- '` - 5Em —Provide copy of Manufacturer's Installation Specifications. 1 Provide signed copy of Cupertino's Tear-Off Policy. ❑�OTJ31yR ReroofApp_2011.doc revised 03/02/11