10070073 CITY OF CUPERTIv0 BUILDING PERMIT
BUILDING ADDRESS: 10318 COLD HARBOR AVE CONTRACTOR:PAK'S ROOFING INC PERMIT NO: 10070073
OWNER'S NAME: TONY&KATHY HOLLAND 1241 SLEEPY HOLLOW LN DATE ISSUED:07/09/2010
VNER'S PHONE: 4089960842 MILLBRAE,CA 94030 PHONE NO:(650)589-2775
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIALP COMMERCIAL
License Class C _3 Lie.# 3 5 RE-ROOF TEAR OFF APPLY 1/2 OSB PLYWOOD DOWN,
�� qq � APPLY
Contractor }�GtR�QCT�� C1G Date 7j�— 30LB BASE FELT DOWN APPLY ELK COOL COLOR 40 YR
I hereby affirm that I am licensed under provisions of Chapter 9 COMP SHINGLE DOWN 30 SQUARES
(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. Sq.Ft Floor Area: Valuation:$1400
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:36909031.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION if
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
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature
Signature Date V All roofs shall be inspected prior to any roofing material being installed.If a roof is
\ _ installed without first obtaining an inspection,I agree to remove all new materials for
inspection. P
.J OWNER-BUILDER DECLARATION 4ttL �^
Signature of Applicant: LDate: �I
I hereby affirm that I am exempt from the Contractor's License Law for one of \.
the following two reasons: ALL ROOF COVE NGS TO BE CLASS"A"OR BETTER
1,as owner of the property,or my employees with wages as their sole compensatior,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
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. 1 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 Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534. `�
Section 3700 of the Labor Code,for the performance of the work for which this //
permit is issued. "M (
Owner or authorized agent: '"V\, Date:
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
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I mus: 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
emnify and keep harmless the City of Cupertino against liabilities,judgments,
is,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting 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
7F
CITY OF CUPERTINO
REROOF
CUPERTINO PERMIT APPLICATION
/cam-7 � '3
APN# V Q 031 (0U Date: .7_ Cil C
Building Address: �, �Cl
IQ 3 $ CG iJ Hark �' ��@ Ci r�rn
Owner's Name: 7,nl je�`, hU fIct od Phone #: 41og_
HOA: Yes ❑ No ❑ If Yes, provide letter from HOA
Contractor: ph r-_�5 tic' c fl o C.- Phone #: 6 50-5P1-,?--7-7�Fax#:
Cupertino Business License #: 3 '1�, Contractor License
#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles 0 Asphalt Shingles �Cof C �"�
❑ Wood Shakes ❑ Wood Shakes 4tq-* tom.4114
❑ Wood Shingles ❑ Wood Shingles
❑ Other (Specify) ❑ Other (Specify)
Number of existing coverings 3G S ❑ Provide I.C.C.E.S. Report #
To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description: �/� e Yep'. ( `C�S�� -A .
Appitj '(2" t-491?
A 1 ELK Coe--_1 (01L--x -irrani�j 6c)1j;c5;4-cyL sh nj&_ vccr, .
Residential Pq Commercial
Green Building: Please complete relevant portion of the Conf rmed 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:
I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
Signature
Revised 02/05/09
CITY OF CUPERTINO
3 ITEMS OF 3 PERMI" RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: Twp: Rng: Sub: B1}:: Lot :
APN . . . . . . . . : 36909031. 00
DATE ISSUED. . . . . . . : 07,'09/2010
RECEIPT #. . . . . . . . . : BS000010830
REFERENCE ID # . . . : 10070073
SITE ADDRESS . . . . . : 10:318 COLD HARBOR AVE
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CU13ERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : TOIdY & KATHY HOLLAND
ADDRESS . . . . . . . . . . : 10:318 COLD HARBOR AVE
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-3328
RECEIVED FROM . . . . : PAKS' ROOFING
CONTRACTOR . . . . . . . : PAKIS ROOFING INC LIC # 31781
COMPANY . . . . . . . . . . : PAD'S ROOFING INC
ADDRESS . . . . . . . . . . : 12.11 SLEEPY HOLLOW LN
CITY/STATE/ZIP . . . : MI:JLBRAE, CA 94030
TELEPHONE . . . . . . . . : (61-30) 589-2775
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- - --------- ---------- ---------- ----------
1BCBSC VALUATION 1, 400 . 00 1. 00 0 . 00 1 . 00 0. 00
1BSEISMICR VALUATION 1,400 . 00 0 .50 0 . 00 0 .50 0. 00
1REROOFRES SQ FEET 30 . 00 390. 00 0 . 00 390 . 00 0. 00
- --------- ---------- ---------- ----------
TOTAL PERMIT 391.50 0 . 00 391 . 50 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 391. 50 7448
---------------
TOTAL RECEIPT 391 . 50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF