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11100117 (2) CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10141 EMPIRE AVE CONTRACTOR:CALIFORNIA STYLE PERMIT NO: 11100117 ROOFING OWNER'S NAME: WEYHE ROBERT AND SHEILA ET At 164 MARIAN LN DATE ISSUED: 10/18/2011 'NER'S PHONE: 4087721928 SAN JOSE,CA 95127 PHONE NO:(408)592-4596 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL U COMMERCIAL0 License Class Lic.# 7-o� RE-ROOF 16 SQ-REMOVE ASHPALT W/COMP EXISTING /e/Wit r!� ( SHEATHING REMAINS Contractor / ' ate I hereby affirm that I am licensed rider the provisions of Chapter 9 (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 whichthis permit is issued. Sq.Ft Floor Area: Valuation:$6000 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 APN Number:32624009.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the Issued by: Date: granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. - 1 / RE-ROOFS: Signature 447,11 Date / / ! All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspecti agree to remove all new materials for inspection. t OWNER-BUILDER DECLARATION ( " Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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, Business&Professions Code) I,as owner of the roe y g HAZARDOUS MATERIALS DISCLOSURE property,rty,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Nbmicipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by / the Health&Safety Code,Sections 25505, d 25534. Section 3700 of the Labor Code,for the performance of the work for which this 1 Date: l k k( Owner or authorized agent: permit is issued. I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY 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 I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address 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 ARCHITECT'S DECLARATION `-demnify and keep harmless the City of Cupertino against liabilities,judgments, 's,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. anting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional 9.18. Signature Date Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 C U P E RT I N O Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: o �� -rt Ave PERMIT# OWNER'S NAME: PHONE# Q� GENERAL CONTRACT R: rrt ,� �� �� BUSINESS ICENSE# ADDRESS: 4 [t-1_ CITY/ZIPCODE: i .� ��� . *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRAC ORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: �- Signature ate Please check applicable subcontractors and complete the following information: 6/ SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum/Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Painting /Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Ow er Contractor Signature Ifate CITY OF CUPERTINO PERMIT RECEIPT OPERATOR: SylviaM 3 ITEMS OF 3 COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 32624009.00 DATE ISSUED. . . . . . . : 10/18/2011 RECEIPT ##. . . . . . . . . BS000015070 REFERENCE ID # 11100117 SITE ADDRESS 10141 EMPIRE AVE SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER WEYHE ROBERT AND SHEILA ET AL ADDRESS 165 LEWIS RD # 10 CITY/STATE/ZIP SAN JOSE CA, 95110 RECEIVED FROM CALIFORNIA STYLE CONTRACTOR MT2WO INOR LIC # Z2531 COMPANY CALIFORNIA STYLE ROOFING ADDRESS 164 MARIAN LN CITY/STATE/ZIP SAN JOSE, CA 95127 TELEPHONE (408) 592-4596 �- FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ----- 1BCBSC VALUATION 6, 000 .00 1. 00 0. 00 1 .00 0'.0 1BSEISMICR VALUATION 6, 000 .00 0.60 0. 00 0 .60 0.00 1REROOFRES SQ FEET 16 . 00 224. 00 0. 00 224 .00 ------0_00 ---------- ---------- --- ------ TOTAL PERMIT 225 .60 0. 00 225 .60 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- ------------ -- CHECK 225.60 1464 --------------- TOTAL RECEIPT 225 .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 CUPERTINQ (408)777-3228 • FAX(408)777-3333 • building an-cupertino.org PROJECT ADDRESS © ' A" AFN# 2-W � U()�A 12 •/p 1 OWNERNANIE i E-MAIL r �[ STREET ADDRESS CITY, STATE,ZIP FAX APPLICANT NAME PHONE E-MAIL STREET ADDRESS CITY,STATE,ZIP FAX C3 OWNER 11 OWNER-BUILDER ❑ OWNER AGENT XCONTILACTOR El CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER11DEVELOPER ❑ TENANT CONTRACTOR N r 0LICENSE NUMBER` J/ LICENSE TYPE r�Q BUS.LIC.# s4nje4 A] COMPANY N X v-1 � E-MAIL Q , FAX STREET ADDRESS t I-� L / rSTATE ZIP PHO ARCHITECT/ENGINEER NAME f l 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: STRUCTURE: ❑ Commercial [ CJ EXISTING ROOF TYPE: ❑BUILT-UP ROOF P<kSPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY) REMOVE/REPLACE . YES IF NO, PLYWOOD ❑ 'v ❑ PLYWD ❑ OSB PTrCH ROOF ❑ NO #LAYERS: THICKNESS: 115/S" TYPE: ❑ CDX '1 Z CLASS: A PROPOSED ROOF TYPE: ❑BUILT-UP ROOF X.SPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT# DESCRIPTION OF WORK 011 a 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 re Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construction. a Eepresentatives of Cupertino tc enter the above-identifi d pr op prQrt;For inspection purposes. el Signature ofApplicant/Agent Date: /G' SUPPLEMENTAL INFORMATION REQUIRED If building is associated with a Home Owners Association,provide letter Z-0 _ Z of approval from HOA. _ el��' - ztAx>;vrv�-�r —Provide Planning approval to verify if there any restrictions. Zia _ Provide copy of Manufacturer's Installation Specifications. rovide signed copy of Cupertino's Tear-Off Policy. 1 -�—� � -4 ReroofApp_201 Ldoc revised 03/02111