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11040115 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10924 NORTHVIEW SQ CONTRACTOR:FOUR SEASONS ROOFING PERMIT NO: 11040115 OWNER'S NAME: FUJIO ISHIHARA PO BOX 1668 DATE ISSUED:04/18/2011 Ol`^'FR'S PHONE: 4082780330 SAN JOSE,CA 95109 PHONE NO:(408)278-0330 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH r— RESIDENTIAL f— COMMERCIAL Contract ADate l'o 1.1 I hereby affir� that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RE-ROOF REMOVE EXISTING CEMWOOD ROOF& (commencing with Section 7000)of Division 3 of the Business&Professions INSTALL NEW 30#UNDERLAYMENT&GAF GRAND CANYON ASPHALT Code and that my license is in full force and effect. SHINGLES.COLOR:STONEWOOD,HAS EXISTING PLYWOOD 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 permit is issued. Sq.Ft Floor Area: Valuation:$4400 APPLICANT CERTIFICATION J 1 certify that I have read this application and state that the above formation is APN Number:31636060.00 Occupancy Type: 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 indemnify and kee harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expens s which m accrue agai t said City in consequence of the granting of this p it. Ad iti ally,the p icant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-poin ource re ul tions per a upertino Municip Code Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature Date Issued by: 1 Date: C OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected for to oofing ma ria being installed.If a roof is [,as owner of the property,or my employees with wages as their sole compensation, installed without first obt ' ng an nspe tion,I agr t remove all ne materi Is for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) ( l 1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I 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 performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain 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(a)should I store or handle hazardous material. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as fined by the y Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's main �tl comp an a with the ertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Healt ` Safe C de,Section 5505,2553Mand553become subject to the Worker's Compensation provisions of the Labor Code,I mustforthwith comply with such provisions or this permit shall be deemed revoked. n r or autho ' ed agent: - Date• l APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of Hork's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name indemnify and keep harmless the City of Cupertino against liabilities,judgments, cr and expenses which may accrue against said City in consequence of the Lender's Address g g of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 3 ITEMS OF 12 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 31636060. 00 DATE ISSUED. . . . . . . : 04/18/2011 RECEIPT #. . . . . . . . . BS000013210 REFERENCE ID # . . . : 11040115 SITE ADDRESS . . . . . : 10924 NORTHVIEW SQ SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : FUJIO ISHIHARA ADDRESS 10924 NORTHVIEW SQ CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM FOUR SEASONS ROOFIN CONTRACTOR DIAZ, ALFRED LIC # 21323 COMPANY . . . . . . . . . . : FOUR SEASONS ROOFING ADDRESS . . . . . . . . . . : PO BOX 1668 CITY/STATE/ZIP . . . : SAN JOSE, CA 95109 TELEPHONE (408) 278-0330 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 4,400 . 00 1. 00 0. 00 1.00 0.00 1BSEISMICR VALUATION 4,400 .00 0.50 0.00 0.50 0 .00 1REROOFRES SQ FEET 14 . 00 182 . 00 0. 00 182 .00 0.00 ---------- ---------- ---------- ---------- TOTAL PERMIT 183 .50 0.00 183 .50 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 La (408) 777-3228 • FAX(408)777-3333 • building(a-)cupertino.org CUPERTINO PROJECT ADDRESS 'O�'/ v i ' /-�� APN# /„r)rQ OWNER NAME1 PHO � 7,5'-03-30 E-MAIL L; 1 c� STREET ADDRESS CITY, STATE,ZIP FAX APPLICANT NAME \ /' PjiONE STREET ADDRESSrD Z 1 U f�i S-T` CITY,STATE, �L `�v�_ </ FA Zee ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMEn �1 LICENSE NUMBER LICENSE TYPE BUS LIC # .2d2c� ( 2 ire c &I a COMPANY NAME r SQc: n r ' E-MAIL FAt`�_�.` STREET ADDRESS ` 1 Gp�f� CITY,STATE ZIP P ONE Sb Z 46rT. , C.4 - // Z obi 27S-0330 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC.# CONLPANY NAME E-MAIL FAX STREET.ADDRESS CITY,STATE,ZIP PHONE USE OF ❑ SFD or Duplex Multi-Family ROOF AREA VALUATION: STRUCTURE ❑ Commercial /YA Gl, EXISTING ROOF TYPE BUILT-UP ROOF ❑ASPHALT SHINGLES 1:1 WOOD SHAKES El WOOD SHINGLES R(SPECIFY)/ 'nM�4� REMOVE rREPLACE >3oZES IF NO, PLYWOOD ❑ %" ❑ PLYWD ❑ OSB PITCH: 1. ROOF ❑ NO #LAYERS THICKNESS: ❑ 5/8" TYPE: ❑ CDX 12 CLASS: A PROPOSED ROOF TYPE: ❑BUILT-UP ROOF �$PHALT 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 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 dI ng nstruction. I authorize representatives of Cupertino to enter the above-identified�property for inspection purposes. Signature of Applicant/.Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED 'p + ' k':`of icEust oLvir 0 Ifbuilding is associated with a Home Owner's Association,provide letter PLAN CHECKTY�E�, ROUTING SLIP of approval from HOA. ❑ 0VERTJM COUNTER ❑ BUILDING"PLAN REVIEW Provide Planning approval to verify Lf there an restrictions. Cl E?CPRES3 � �• ❑ PLANNING PLAN REVIEW Provide copy of Manufacturer's Installation Specifications. ❑ STANDARD ❑ FIREDkpr Provide signed copy of Cupertino's Tear-Off Policy. ❑ OTHER: . ReroofApp_2011.doc revised 03/02/11