11010113 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11139 SUTHERLAND AVE CONTRACTOR:SHADOWFAX ROOFING PERMIT NO: 110 10 113
OWNER'S NAME: VENKATA UPPULURI 1366 SANTA FE DR DATE ISSUED:01/20/2011
0—"JER'S PHONE: 4082576900 SAN JOSE,CA 95118 PHONE NO:(408)265-2490
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REMOVE OLD SHAKE ROOF,COVER W/7/16"OSB RADIANT
BARRIER,PRESIDENTIAL TL,ASPHALT LIFETIME SHINGLE
License Class ` ` Lic.# CLASS"A"29 SQUARES.
Contractor s`��tA�6�1--J� %Date
3G/
I hereby affirm that I am licensed under th 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: Sq.Ft Floor Area: Valuation-$14500
t. 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. APN Number:35617064.00 Occupancy Type:
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the workor which this
permit is issued. (4� PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR
I certify that[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 180 DAYS FROM LAST CALLED INSPECTION.
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save Date: U-((
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Issued b,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply with
all non-point cc regulations p r e Cupertino Municipal Code, ection .18. RE-ROOFS:
Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
Signature ?� installed without first obtaining an inspection,I agree to remove all new materials for
inspection. / r
r OWNER-BUILDER DECLARATION Signature of Applican Date:
I uereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
the following two reasons:
t. I,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 HAZARDOUS MATERIALS DISCLOSURE
sale(Sec.7044,Business&Professions Code)
2. 1,as owner of the property,am exclusively contracting with licensed contractors to I have read the hazardous materials requirements under Chapter 6.95 of the
construct the project(Sec.7044,Business&Professions Code). California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
I hereby affirm under penalty of perjury one of the following three declarations: Additionally,should I use equipment or devices which emit hazardous air
i. I have and will maintain a Certificate of Consent to self-insure for Worker's
contaminants as defined by the Bay Area Air Quality Management District I will
Compensation,as provided for by Section 3700 of the Labor Code,for the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
performance of the work for which this permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
2. 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 O e or authorize en
permit is issued. Date: / l/
3. 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 I hereby affirm that there is a construction lending agency for the performance of work's
become subject to the Worker's Compensation provisions of the Labor Code,I for which this permit is issued(Sec.3097,Civ C.)
must forthwith comply with such provisions or this permit shall be deemed Lender's Name
revoked.
Lender's Address
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is ARCHITECT'S DECLARATION
correct.I agree to comply with all city and county ordinances and state laws relating I understand my plans shall be used as public records.
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Licensed Professional
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
r -Is,and expenses which may accrue against said City in consequence of the
ing of this permit.Additionally,the applicant understands and will comply with
a,,non-point source regulations per the Cupertino Municipal Code,Section 9.18.
Signature Date
C
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT 1 N O �� Fax: 408-777-3333
CONTRACTO / BCONTRACTOR LIST
JOB ADDRESS: / PERMIT#
OWNER'S NAME: Yc.fie PHONE#
GENERAL CONTRACTOR: BUSINESS LICENSE# 46 05�f
ADDRESS: - � CITY/ZIPCODE: 5-fA 14-w. S_11
*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 SU ONTRACT S HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors: 3 el
Signatu ate
Please check applicable subcontractors and complete the following information:
V 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
OwA/Cractor Signature D to
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35617064 . 00
DATE ISSUED. . . . . . . : 01/20/2011 /
RECEIPT #. . . . . . . . . : BS000012531
REFERENCE ID # . . . 11010113
SITE ADDRESS . . . . . : 11139 SUTHERLAND AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : VENKATA UPPULURI
ADDRESS . . . . . . . . . . : 11139 SUTHERLAND AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : JERRY SHAFFER
CONTRACTOR . . . . . . . : JERRY SHAFFER LIC # 27342
COMPANY . . . . . . . . . . : SHADOWFAX ROOFING
ADDRESS . . . . . . . . . . : 1366 SANTA FE DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95118
TELEPHONE . . . . . . . . : (408) 265-2490
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 14, 500 .00 1. 00 0 . 00 1 . 00 0 . 00
1BSEISMICR VALUATION 14, 500 .00 1.45 0 . 00 1 .45 0 . 00
1REROOFRES SQ FEET 29 .00 377. 00 0 . 00 377 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 379.45 0 . 00 379 .45 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 379.45 MC
---------------
TOTAL RECEIPT 379.45
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
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 11139 sutherland ave. DATE: 01/20/2011 REVIEWED BY: bobs.
APN: BP#: VALUATION: $14,500
*PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY PENTAMATION 1 SFDWLROOF
USE: SFD or Duplex PERMIT TYPE:
WORK replace shake roof with corn osition shingle.
SCOPE
FEE ID ROOF AREA
s.f.
1REROOFFRES 2,900
/ f_I_ Pl.za C'h_'c°1t!
();'Itt'r`Much I+i ,. C)tiz ,°17 t t't;i t.,f Oi 'f`L'> c Inst
dlath.Itast� 1�`e:
1'.trzrzz:t, 1i.7;. 1 c: lle, his,'?.
NOTE: These ees are based on the relimina in ormation available and are onlyan estimate. Contact the Dept or addno.
'l info.
FEE ITEMS (I ee Resolution 09-OS 1 Eff 711;101 FEE Q
TY/FEE MISC ITEMS
f'lzrrnh.':tfe�1� 'l:lec Pk411 Check:
Permit Fee: $377.00
Supp/. last;I' e
f'1zfrr7lt.: tlfi°1a `Iiec' t%'lit ''ee':
f'lurrzh./_lf<:c•lr %7:aE:z� 1'a�rt�Jtf/'�'e:
('onswitc[ion Tax
,Icolwictfl
Work Without Permit? 0 Yes E) No $0.00
1'lunniss�7 F'ctc s`:
It-trG>el l�c�ettl�re:r�ftrtrr,r2 Fees= �
Strong Motion Fee: IBSEISMICR $1.45 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS:' $379.45 $0.00 TOTAL FEE: $379.45
Revised: 01/03/2011
CITY OF
CITY OF CUPERTINO
REROOF
C U P E RT I N O PERMIT APPLICATIONAPN 7
Date: Z�� l
If residential, is house an Eichler? Yes No �If yes, needs planning approval.
Building Address: Z'
Owner's Name: � Phone #:
HOA: Yes ❑ No If yes, provide letter from HOA �6r aS� _6
Contractor: Phone #:
-Awn DA,)/' �j Fax#.
Cupertino Business License #: Contractor License #:
-7-3 ��-
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles Asphalt Shingles
,te�,Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) ❑ Other (Specify)
Number of existing coverings 1 ❑ Provide I.C.C.E.S. Report #
To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description:
Residential Commercial ❑
Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if
Green Building Checklist & attach it to the application or if there are any restrictions: ❑
applicable, include in plan set & the sheet index.
Valuation:
Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy: