14010011 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20421 PACIFICA DR CONTRACTOR:PLATINUM ROOFING INC PERMIT NO: 14010011
OWNER'S NAME: FRANGADAKIS LEON AND ELAINE 1900 DOBBIN DR DATE ISSUED:01/02/2014
OWNER'S PHONE: 4082551020 SAN JOSE,CA 95133 PHONE NO:(408)280-5028
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie.# r T_
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby of rm that I am licensed unde the provisions of C Ater 9 JOB DESCRIPTION:RE-ROOF OVERLAY 115 MIL SINGLEPLY MEMBRANE
(commencing with Section 7000)of Division 3 of the Business&Professions OVER
Code and that my license is in full force and effect. THE(E)BUILT UP ROOFING,20 SQRS.
I f
6y—affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Wor4cer'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.Ft Floor Area: Valuation:$16533
permit is issued.
�C'
APPLICANT CERTIFICATION APN Number:36940011.20421 Occupancy Type:
I fy at 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulatign&ner.the Cupertino Municipal Code,Section
9 18. �---' �I
Signature DateL*/� Issued by:, � � Date: l• 1
❑ O E - UILDER DECLARATION
11 RE-ROOFS:
I hereby affirm t at I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance 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.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner !F u tori tt: 4W11 forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is 1 hereby oeis
rm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which permit is issued(Sec.3097,Civ C)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9 18. I understand my plans shall be used as public records.
Signature Date Licensed Professional
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333•build ingacupertino.org
PROJECT ADDRESS � 7 I nay6 r O y. APN# 11'b J 0
OWNER No`AME„Q t r�L{ P ONS E-MAILIV
`
STREET ADDRESS I r 0 CITY, STATE ZIP ' 9.x'0!
CONTACT NAME Se! 4 PHONE J A�y�r E-MAIL G7
STREET ADDRESS CITY,STATE, ZIP g b 3 FAX
S ca��►�
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR EVCONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME Ol LICENSE NUMBER LICENSE TYPE /_�ZO BUS.LIC.# ag0�
-"` COMPANY NAME E-MAIL G• FA&
0
8
STREET ADDRESS/A� dobd rn CITY,STATE,ZIP 573-3 PHONF! � O
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC.#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF 0SFD or Duplex El Multi-Family ROOF AREA:Q.,047C) s VALUATION: /
STRUCTURE: 5/Commercial �3-3
EXISTING ROOF TYPE: IJP ISUILT-UP ROOF ❑ASPHALT SHINGLES ,❑/ ❑WOOD SHAKES WOOD SHINGLES El OTHER(SPECIFY)
REMOVE/REPLACE ❑yES IFNO, PLYWOOD l '/:" ElPLYWD 13 OSB PITCH: I, ROOF
,L-r-JJN0 #LAYERS: O4I THICKNESS: ❑ 5/8" TYPE: ErCDX / :12 CLASS: A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF 11 ASPHALT SHINGLES El WOOD SHAKES 11 WOOD SHINGLES ❑OTHER r ICC-ES REPORT#
DESCRIPTION OF WORK: 6
,A^
A,00(2 S� d
By my signature below,I certify to each of g I�amtheroperty owner or authorized agent to act on the property owner's behalf. I have read this
application and the infonnati is correct. I escription of Work and verity it is accurate. I agree to comply with Il applicable local
ordinances and state laws r lacing to building nstru ion. e repr sentatives of Cupertino to enter the above-identified roperty for i pe i p poses.
Signature of Applicant/Agent Date:
2,
SUPPLEMENTAL A REQUIRED /OFFICE,-USE LY
If building is associated with Ho Owner's Association,provide letter PLAN,CHECKTYPE ROUTING SLIP
of approval from HOA. OVER-THE-COUNTER BUILDING PLAN REVIEW
Provide Planning approv to verify if there any restrictions. ❑. EXPRESS L_I PLANNING PLAN REVIEW
Provide copy of Manufacturer's Installation Specifications. ❑ STANDARD= ❑ FREDEPT
Provide signed copy of Cupertino's Tear-Off Policy. ❑ OTHER:
ReroofApp_2011.doc revised 03/16/11
CITY OF CUPERTINO
FEE ESTIMATOR—BUILDING DIVISION
ADDRESS: 20421 PACIFICA DR DATE: 01/02/2014 REVIEWED BY: SEAN
APN: BP#: (/ *VALUATION: 1$16,533
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY PENTAMATION
USE: Commercial Building PERMIT TYPE: 1COMMLROO
WORK OVERLAY 115 MIL SINGLEPLY MEMBRANE OVER THE EXISTING BUILT UP ROOFING 2000 SQ
SCOPE FT)
IF
NMI ME11MI
Mesh. Plan Check Phnnb. flan Check Elec.Plan{.;heck
Fch.Perrnit Fee: Plumb. Permit ree: Elec. Permii Fee:
F
Hech.Insp. Other Plumb Insp. Outer Elec.Insp..Insp.Fee: Plumb. hisp.Fee: Elec.Insp,Fee:
NOTE:This estimate does not include fees due to other Departments(La Planning,Public Works,Fire,Sanitary Sewer District,,
District,etc). These fees are based on the prefindna information available and are only an estimate- Contact the De t or addn7 info.
FEE ITEMS(Fee Resolution 11-053 E . 7/1/13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00F2_,0001 s.f. Re-roof
Suppl.PC Fee: 0 Reg. ® OT 0.0 hrs $0.00 $383.00 IREROOFCOM
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp.Fee.0 Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Conslruction Tax:
A.dininistrative Fee:
Work Without Permit? ®Yes (E) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Travel Documentation Fees.; Building or Structure
i
Strong Motion Fee: IBSEISMICO $3.47 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
$4.47 r$383.00 v " 4 t O FEE, $387.47
Revised: 10/01/2013