11040119 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11500 CHARSAN LN CONTRACTOR:WESTSHORE ROOFING PERMIT NO: 11040119
INC
OWNER'S NAME: MARISSA KOBYLENSKI 2245-A FORTUNE DR DATE ISSUED:04/18/2011
ER'S PHONE: 4082530237 SAN JOSE,CA 95131 PHONE NO:(408)694-0060
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RE-ROOF TEAR OFF WOODSHAKE&REPLACE WITH
(commencing with Section 7000)of Division 3 of the Business&Professions COMP
Code and that my license is in full force and effect. 4.81,13 PER SQ CLASS A 30SQ
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
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$16000
permit is issued.
APPLICANT CERTIFICATION APN Number:36210043.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signature Date Issued by: Date:
L OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(x)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of NAork's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
nify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18• I understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36210043 . 00
DATE ISSUED. . . . . . . : 04/18/2011
RECEIPT #. . . . . . . . . : 99000000481
REFERENCE ID # . . . : 11040119
SITE ADDRESS . . . . . : 11500 CHARSAN LN
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER MARISSA KOBYLENSKI
ADDRESS . . . . . . . . . . : 11500 CHARSON LN
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-4974
RECEIVED FROM . . . . : PAUL FOWLER
CONTRACTOR . . . . . . . : PAUL FOWLER LIC # 21417
COMPANY . . . . . . . . . . : WESTSHORE ROOFING INC
ADDRESS 2245-A FORTUNE DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95131
TELEPHONE (408) 694-0060
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
OLBCBSC VALUATION 16, 000.00 1. 00 0. 00 1.00 0. 00
OLREROOF SQUARES 30 .00 390. 00 0. 00 390 .00 0.00
OLSEISM VALUATION 16, 000 .00 1.60 0. 00 1 .60 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 392 .60 0. 00 392 .60 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 392 .60 MC
---------------
TOTAL RECEIPT 392.60
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