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10060136 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10964 NORTHSEAL SQ CON TRACTOR:FOUR SEASONS ROOFING PERMIT NO: 10060136 OWNER'S NAME: HESSAM MOGHTADER PO BOX 1668 DATE ISSUED:06/22/2010 NER'S PHONE: 4082296000 SAN JOSE,CA 95109 PHONE NO:(408)278-0330 ❑ LICENSED CONTRACTOR'S DECLARATION BUI:.DING PERMIT INFO: BLDG ELECT r— PLUMB r License Class Lic.# �� MECH r— RESIDENTIAL COMMERCIAL Contractor Date � r--�� DC7 I hereby affirm th t I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RE-ROOF RMV EXTNG CEMWOOD ROOF.INSTALL NEW (commencing with See r n 7000)of Division 3 of the Business&Professions C'� GRA,41)CANYON ASPHALT COMP 50YR ROOF SYSTEM Code and that my license is in full force and effect. "STC NEWOOD"IN COLOR CLASS A 14SQ 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 Sq.1't Floor Area: Valuation:$3188 permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is AP?` Number:31640031.00 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, ,?ERMIT 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. Z,,-!,2,) Signature r -' Date L��a �w Issued by: Date: Li 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 i oofs 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, inti Iled 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, insp:ction. Business&Professions Code) "9,-;> 'QC) I,as owner of the property,am exclusively contracting with licensed contractors to Sigr atu Applicant:- - — Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three �LLROOFCOVERINGS 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. Cal forma Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by con pliance 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 con:aminants 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 Hef Ith&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 or rtI' rrzed agent: a l cilate: 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 Nhich this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Ler der's Name -mify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the Ler der's Address granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. I ur derstand my plans shall be used as public records. Signature Date Lic.-used Professional CITY OF CUEERTINO 3 ITEMS OF 18 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Iot: APN . . . . . . . . : 31640C31 . 00 DATE ISSUED. . . . . . . : 06/22/2010 RECEIPT #. . . . . . . . . BSOOOC10685 REFERENCE ID # . . . : 10060136 SITE ADDRESS . . . . . : 10964 NORTHSEAL SQ SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : HESSADI MOGHTADER ADDRESS 10964 NORTHSEAL SQ CITY/STATE/ZIP . . . : CUPER"INO, CA 95014 RECEIVED FROM . . . . : FOUR SEASONS ROOFIN CONTRACTOR . . . . . . . : DIAZ, ALFRED LIC # 21323 COMPANY . . . . . . . . . . : FOUR "EASONS ROOFING ADDRESS . . . . . . . . . . : PO BO:,' 1668 CITY/STATE/ZIP . . . : SAN JOSE, CA 95109 TELEPHONE . . . . . . . . : (408) :?78-0330 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---- ------ ---------- ---------- ---------- 1BCBSC VALUATION 3, 188 . 00 1 . 00 0 . 00 1. 00 0 . 00 1BSEISMICR VALUATION 3, 188 . 00 0 . 50 0 .00 0 . 50 0 . 00 1REROOFRES SQ FEET 14 . 00 L82 . 00 0 . 00 182 . 00 0 . 00 ---- ------ ---------- ---------- ---------- TOTAL PERMIT L83 .50 0 . 00 183 .50 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- - ------------------- CHECK 1, 101 . 00 #D09766 --------------- TOTAL RECEIPT 1, 101 . 00 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 604 ROOF IN-PROGRESS 605 FINAL REROOF CITY OF C c) l! C/' CITY OF CUPERTINO REROOF C U P E RT I N O PERMIT APPLICATION Date: l Building Address: i. / Phone #: Owner's Name: � S S IU�t�c HOA: Yes No ❑ If yes, provide letter from HOA ^ Contractor: Phone #:�� ' �s o�J f '��"".y C�� -4�"0 3 3 Fax #: I i Cupertino Business License #: Contractor License #: Type of Roof Covering: Existing: Proposed: Built-Up Roof ❑ Built-Up roof �:i Asphalt Shingles Asphalt Shingles Wood Shakes ❑ Wood Shakes Wood Shingles p ❑ Wood Shingles Other (Specify), �2�/�oa�J�G� ❑ Other (Specify) i Xumber of existing coverings a Provide LC.C.E.S. Report # :1 To be Removed ❑ Provide Mfgr. Installation Specs. e0 Job Description: Az~de 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: ❑ j applicable, include in plan set & the sheet index. 1, Valuation: 1 Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy: Signature Revised 02/05/09