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13080125CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20875 VALLEY GREEN DR CONTRACTOR: NEMMER ROOFING PERMIT NO: 13080125 OWNER'S NAME: KORET FOUNDATION 5348 AUDUBON PARK CT DATE ISSUED: 08/16/2013 OWNER'S PHONE: 6505923960 FREMONT, CA 94538 PHONE NO: (510) 919-2930 ❑ JOB DESCRIPTION: RESIDENTIAL 0 COMMERCIALE] /i ? 4 LICENSED CONTRACTOR'S DECLARATION License Class Li,. # BLDG 200-221- RE -ROOF TEAR OFF, INSTALL OSB AND REROOF WITH COMP CLASS A q� S� Contractor /Ue- + en, d e t I hereby affirm that I am licensed under 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 Sq. Ft Floor Area: Valuation: $14651 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 e a or Code, for the performance of the work for which this APN Number: 32609064.00 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 WITIiIN 0 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 DAY M 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: U with all non -point source reations per the Cupertino Municipal Code, Section 9.18. �— � _� 6 f � RE -ROOFS: Signatur Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without fust obtaining an inspection, I agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION 6 Signature of Applicant: v�"'ait8' 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 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 sale (Sec.7044, Business & Professions Code) I, 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 25505,20P3 and 25534. Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Owner or authorized agent: 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 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 indemnify and keep harmless the City of Cupertino against liabilities, judgments, ARCHITECT'S DECLARATION costs, 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 CUP R'T'INO. REROOF PERMIT APPLICATION / COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION �(}� 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 �O �f (408) 777-3228 - FAX (408) 777-3333 - building(ckupertino.org 01 PROJECT ADDRESS! G. i �G✓�V J `AII, OWNER NAME �i �C�"YRI PHONE E-M STREETAD© FAX CONTACT NAME PHONE E-MAIL STREET ADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHrrECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME j �� /J /� -j ,%I LICENSE NUMBEOR 7�5 � P� - BUS. LI 89c). COMPANY NAME P /I IL / `/ E-MAILC� FAX STREET ADD S s3 CITY STATE, ZIP „L 9 PHONE 5�0 �� �4�d ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC. # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE USE OF ❑ SFD or Duplex ❑ Multi -Family STRUCTURE: El ROOF AREA: VALUATION: EXISTING ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER (SPECIFY) REMOVE /REPLACE ❑ YES ❑ NO IFNO, I # LAYERS: PLYWOOD ❑ '/.- ❑ THICKNESS: 115/8" PLYWD ❑ OSB TYPE: 11CDX PITCH: ' 12 ROOF CLASS: PROPOSED ROOF TYPE: ❑ BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER ICC -ES REPORT # DESCRIPTION OF WORK: 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 relating t ding construc ' uthorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: Date: 8 `� SUPPLEMENTAL INFORMATION REQUIRED _ If building is associated with a Home Owner's Association, provide letter of approval from HOA. Provide Planning approval to verify If there any restrictions. Provide copy of Manufacturer's Installation Specifications. Provide signed copy of Cupertino's Tear -Off Policy. 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