11050018 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20255 NORTHGLEN SQ CONTRACTOR:FOUR SEASONS ROOFING PERMIT NO: 11050018
OWNER'S NAME: KRAUSS WILLI PO BOX 1668 DATE ISSUED:05/03/2011
OWNER'S PHONE: 4082552874 SAN JOSE,CA 95109 PHONE NO:(408)278-0330
G LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT[_ PLUMB r
License Class Lic.# / D
MECH r— RESIDENTIAL r— COMMERCIAL�
Contractor Date 3
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RE-ROOF REMOVE EXISITNG 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. 9t-
Sq.Ft Floor Area: Valuation:$4400
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:31639009.00 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 keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18. )
Signature ' Date "// Issued by:!�� - Date:
L
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 prior to any roofing material being installed.If a roof is
1,as owner of the property,or my employees with wages as their sole compensation, installed without firstobtaining an ins ection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. �)
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Signature of App scant: Dater
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
I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. 1 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 defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. Owner oanth r— � r /
Date: �
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of work'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,
co,' -nd expenses which may accrue against said City in consequence of the Lender's Address
gi ;of this permit.Additionally,the applicant understands and will comply
wiit..,.,ii 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 18 PERMIT RECEIPT OPERATOR: TraciC
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 31639009.00
DATE ISSUED. . . . . . . : 05/03/2011
RECEIPT #. . . . . . . . . : BS000013366
REFERENCE ID # . . . : 11050018
SITE ADDRESS . . . . . : 20255 NORTHGLEN SQ
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . . KRAUSS WILLI
ADDRESS . . . . . . . . . . : 20255 NORTHGLEN 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
ot
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
(408)777-3228 • FAX(408)777-3333• buildinq(c2icupertino.org
CUPERTINO
PROJECT ADDRESS ^G J / ^ 71PN I
OWNER NAME O( 5 t� PHONE E-MAIL v
$ . �,,�5 lli S'
STREET.ADDRESS CITY, STATE,ZIP FAX
APPLICANT NAME -3P ONE E-MAIL
\ ce Rz�re GAS 7
STREET ADDRESS�O 1 U f�` CITY,STATE, FA
�C . �.n -T6'1-e_ cl • s'</ � F 7t3'' X233
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
CL
2 Ye LICENSE NUMBER �! b LICENSE TYPE BUS.LIC k
\ c� C
COMPANY DAME �( Sem.�- / 1 E-MAIL FA Q/_F),2 -7,?-0�3
STREETADDRESS A CI ,STATE ZIP P ONE
arm �T. t G•4 - // 2 oS)-27Fr-0330
.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:
41
STRUcruRE. El Commercial
Gd
EXISTING ROOF TYPE: 1:1 BUILT-UP ROOF 13 ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES Si�Utl-11=R(SPECIFY)610
0/07
REMOVE/REPLACE N:o :ES IF NO, PLYWOOD ❑ %" ❑ PLYWD ❑ OSB !PITCH: (2 ROOF
❑ NO k LAYERS: THICKNESS: ❑ 5/8" TYPE: ❑ CDX 12 CLASS A
PROPOSED ROOF TYPE. ❑BUILT-UP ROOF ;0<5PHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT k
DESCRIPTION OF WORK:
(�J
S Colorr
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 relatinZtob ing nstruc ion. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: S Ile
SUPPLEMENTAL INFORMATION REQUIRED `
s s ,,O
FR# Ty:[JSE QNL�
If building is associated with a Home Owner's Association,provide letter ' PLANcaEcxTpE x f `ROUTING SLIP "
of approval from HOA. 0VER-THE-COUNT19R': ET BUILDING PLAN REVIEW
Provide Planning approval to Verify if there any restrictions. ❑ EXPRESS' ❑ PLANNING PLAN REVIEW
Provide copy of Manufacturer's Installation Specifications. ❑ STANDARD ❑ FIRE DEPT
Provide signed copy of Cupertino's Tear-Off Policy. ❑ OTHER:
ReroofApp_201 1.doc revised 03/02/11
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 20255 northglen square DATE: 05/02/2011 REVIEWED BY: bobs.
APN: TBP—#: "VALUATION: 1$4,400
PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY SFD or Duplex PENTAMATION 1SFDWLR00F
USE: PERMIT TYPE:
WORK remove existing cemwood roofing, replace with comp shingles.
SCOPE
FEE ID ROOF AREA
s.f.
1 REROOFFRES 1,400
.........L
NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'1 info,
FEE ITEMS (Fee Resolution 09-051 EI
f 7'1!10) FEE QTY/FEE MISC ITEMS
Permit Fee: $182.00
Work Without Permit? 0 Yes (D No $0.00
Strom Motion Fee: IBSEISMICR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $183.50 $0.00 TOTAL FEE: $183.50
Revised: 04/29/2011