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11060028 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20091 FOREST AVE CONTRACTOR:CD ROOFING PERMIT NO: 11060028 OWNER'S NAME: NGUYEN HAI T ET AL 2909 WILBUR AVE DATE ISSUED:06/03/2011 MINER'S PHONE: 4084103649 SAN JOSE,CA 95127 PHONE NO:(408)898-6605 L, LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT PLUMB License Class Lic.# f 2MECH r RESIDENTIAL COMMERCIAL Contractor 119 Date G - 3 — \ f I hereby a arm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REROROF,25 SQUARES,TEAR OFF WOOD SHAKES AND REPLACE WITH COMP,30 YEAR (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:$6000 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. APN Number:31633067.00 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-point source regulations r the Cupertino Municipal Code,Section 9.18. Issued by: Date: Signature Date l' OWNER-BUILDER 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 obtaining 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 Applicant: 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. I 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 Owner or aut zed t: become subject to the Worker's Compensation provisions of the Labor Code,I must Date: 3 - \ t 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 work'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 indemnify 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 ing of this permit.Additionally,the applicant understands and will comply 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 U�� FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 20091 Forest Ave. DATE: 06/03/2011 REVIEWED BY: jsg -4 31 0 33 olp BP#: "'VALUATION: $ PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof PRIMARY PENTAMATION 1SFDWLR00F USE: SFD or Duplex PERMIT TYPE: WORK Wood shakes to 30 Vear comp SCOPE FEE ID ROOF AREA s.f. 1REROOFFRES 2,500 NOTE: These fees are based on the preliminary information available and are only an estimate. Contact the Dept-for addn'1 info. FEE ITEMS (Fee Resolution 09-051 L,4 jt.71U10) FEE QTY/FEE MISC ITEMS Permit Fee: $325.00 Work Without Permit? 0 Yes E) No $0.00 A Strong Motion Fee: 1BSEISMICR ts0.00 Select an Administrative Item Bldg;Stds Commission Fee: $0.00 SUBTOTALS: $325.001 $0.00 TOTAL FEE: $ .00 Revised: 4/29/2 CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: TraciC COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 31633067 . 00 DATE ISSUED. . . . . . . : 06/03/2011 RECEIPT #. . . . . . . . . BS000013648 REFERENCE ID # . . . : 11060028 SITE ADDRESS 20091 FOREST AVE SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER NGUYEN HAI T ET AL ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2008 RECEIVED FROM . . . . : CD ROOFING CONTRACTOR CHARLIE DUONG LIC # 28245 COMPANY CD ROOFING ADDRESS 2909 WILBUR AVE CITY/STATE/ZIP . . . : SAN JOSE, CA 95127 TELEPHONE . . . . . . . . : (408) 898-6605 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 6, 000 . 00 1 . 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 6, 000 . 00 0 .60 0. 00 0 . 60 0 .00 1REROOFRES SQ FEET 25. 00 325 . 00 0 . 00 325. 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 326 .60 0 . 00 326 .60 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 326 . 60 Visa 639664 --------------- TOTAL RECEIPT 326 . 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 REROOF PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333• building(Qcupertino.orq CUPERTINO PROJECT ADDRESS TN OWNER NAME P ONE E-MAIL ►_t0 1 STREET ADDRESS LA CITY, STATE ZIP FAX I okcs c- APPLICANT NAME PHONE^ O J E II 10 t -G: �1 8 STREET ADDRESS CITY,STATE,ZIP NA �a I 1 P Cl 2 ... v �aS ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBERq LICENSE E BUS.LIC.# COMPA AME MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHTTECT/ENGINEER NAME LICENSE NUMBER BUS.LIC.# COMPANY NAME E-MAIL FAX STREET ADDRESS y CITY,STATE,ZIP PHONE USE OF ❑ SFD Or Duplex E},{1ulti-Family ROOF AREA: VALUATION: STRUCTURE: ElCommercial ��,,// &00 v EXISTING ROOF TYPE: ❑BUILT-UP ROOF El ASPHALT SHINGLES L(WOOD SHAKES ❑WOOD SHINGLESOTHER(SPECIFY) I C REMOVE/REPLACE YES F"FNO, PLYWOOD yA'/:" ❑ PLYWD OSB PITCH: ROOF ❑ NO RS: THICKNESS: ❑ 5/8" TYPE: ❑ CDX 12 CLASS: A ICC-ES REPORT# PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER DESCRIPTION OF WORK: ©0 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 tc enter the above-identified property for inspection purposes. Signature of Applicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED _If building is associated with a Home Owner's Association,provide letter ALAN CHECK TI P� m ROUTING SLIP of approval from HOA. ;OVER THE COUNTER ❑ BUILDING PLAN REVIEW _Provide Planning approval to verify if there any restrictions. ❑gEXPREss ❑ PLANNINGPLAN REVIEw ; _Provide copy of Manufacturer's Installation Specifications. ❑; TANDARD ❑ Fizt> DEPT Provide signed copy of Cupertino's Tear-Off Policy. ❑ `� R ReroofApp_2011.doc revised 03/02/11