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11050021 ti CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20285 NORTHGLEN SQ CONTRACTOR:FOUR SEASONS ROOFING PERMIT NO: 11050021 OWNER'S NAME: SCHAFFNER PHILIP J PO BOX 1668 DATE ISSUED:05/03/2011 OWNER'S PHONE: 4082573972 SAN JOSE,CA 95109 PHONE NO:(408)278-0330 G LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r License Class " -11 Lic.# "/ 7.,A ( o D MECH r- RESIDENTIAL r- COMMERCIAL� Contrac Date — I here affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RE-ROOF REMOVE EXISTING CEMWOOD ROOF& (commenc 7900)Mvision 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 I certify that I have read this application and state that the above information is APN Number:31639012.00 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. - Signatu a Date --- 3-1 Issued b�: - 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 prior to any roofing material being installed.If a roof is I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,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) I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applic t: Date: 3 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. California Health&Safety Code,Sections 25505,25533,and 25534. I 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(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 Own 22 forthwith comply with such provisions or this permit shall be deemed revoked. Date: 7 i 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— and expenses which may accrue against said City in consequence of the Lender's Address t. g of this permit.Additionally,the applicant understands and will comply w....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 18 PERMIT RECEIPT OPERATOR: TraciC COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 31639012 . 00 DATE ISSUED. . . . . . . : 05/03/2011 RECEIPT #. . . . . . . . . : BS000013366 REFERENCE ID # . . . : 11050021 SITE ADDRESS . . . . . : 20285 NORTHGLEN SQ SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER SCHAFFNER PHILIP J ADDRESS . . . . . . . . . . : 20285 NORTHGLEN SQ CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-0517 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 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 1, 101 . 00 010873 --------------- TOTAL RECEIPT 1, 101. 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 GUPERTINO (408) 777-3228 • FAX (408)777-3333 • building(Qcupertino.org PROJECT ADDRESS APN 9 OWNER NAME` , PHONE 7- ? Z E-MAIL P SC STREET ADDRESS CITY, STATE,ZIP FAX APPLICANT NANM PjiONE . E-MAIL STREET ADDRESS rD CITY,STATE, ` �v - C+�-• l� FA :G� ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME Q�O 1Ve C LICENSE NUMBER Ll LICENSE TYPE BUS.LIC # CL-zCOMPANY NAME C�IJ( Se,,. n ! I E-MAIL FAtK STREET ADDRESS1Gp�(rV CI ,STATE ZIP PHONE D S-6-z ST. C•� �1 :�// 2 L vS�-27F-t133u ARC HITECT,ENGINEER NAME LICENSE NUMBER BUS.LIC.x COMPANY NAME E-MAIL. FAX STREET ADDRESS CITY,STATE,ZIP PHONE LSE OF ❑ SFD or Duplex ;�Rz2vlulti-Family ROOF AREA. VALUATION: STRUCTURE ❑ Commercial IYA G� EXISTING ROOF TYPE 1�" El h11El3 BUILT-UP ROOF El ASPHALT SHINGLES C3 WOOD SHAKES ❑WOOD SHINGLES XOTFIER(SPECIFY) ;R >a ti REMOVEEPLACE ES IF NO, PLYWOOD " PLYWD OSB !!PITCH: ROOF ❑ NO #LAYERS: THICKNESS: ❑ 5/8" TYPE: ❑ CDX :12 CLASS: A PROPOSED ROOF TYPE. ❑BUILT-UP ROOF ez<SPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT N DESCRIPTION OF WORK. �7 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 relatinatob ing nstruction. I authorize representatives of Cupertino to enter the above-ide tilied property for inspection purposes. Signature of Applicant/Agent: Date: Z SUPPLEMENTAL INFORMATION REQUIRED ?' �� .'' 0MCE USE oNii " �s. t: If building is associated with a Home Owner's Association,provide letter PtnNxECiKT11'La ';"''ROUTING SLIP of approval from HOA. OVER THE COU�ISER .,BUILDING PLAN REVIEW Provide Planning approval to verify ifthere any restrictions. ❑ ExPREss..` ❑' PLANNINGPLAN REVIEW N Provide copy of Manufacturer's Installation Specifications. ❑ 'STANDARD ❑ i IR'E'DEPT _ Provide signed copy of Cupertino's Tear-Off Policy. ❑ OTHER: ReroofApp_2011.doc revised 031'021'11 r •�.. CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 20285 northglen square DATE: 05/02/2011 REVIEWED BY: bobs. APN: BP#: 'VALUATION: 1$4,400 "PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof PRIMARY SFD or Duplex PENTAMATION 1 SFDWLROOF USE: PERMIT TYPE: WORK remove existing cemwood roofing, replace with comp shingles. SCOPE FEE ID ROOF AREA s.f. 1 REROOFFRES 1,400 Lj I NOTE. Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l info, FEE ITEMS jIee Resolution 09-051 1:ff 7;1x'10) FEE QTY/FEE MISC ITEMS Permit Fee: $182.00 Work Without Permit? 0 Yes No $0.00 Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item BldgStds Commission Fee: IBCBSC $1.00 SUBTOTALS: $183.50 $0.00 TOTAL FEE: $183.50 Revised: 04/29/2011