15100131I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 22997 STANDING OAK CT
OWNER'S NAME:
LZ LICENSED CONTRACTOR'S DECLARATION
License Class / Lic. #
Contractor 6o C atf ti Date le) 1 I
I hereby affirm that I am licensed under tKe 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:
1. 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
pe ance of the work for which this permit is issued.
kert
and will maintain Worker's Compensation Insurance, as provided for by
n 3700 of the Labor Code, for the performance of the work for which this
t is issued.
V APPLICANT CERTIFICATION
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,
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 -
/ Date G 6
❑ OWNER' LDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. 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)
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
1. 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.
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
permit is issued.
3. 1 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
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.
APPLICANT CERTIFICATION
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,
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 source regulations per the Cupertino Municipal Code, Section 9.18.
Signature
Date
ACTOR-'
PERMIT NO: 15100131
'3533 DP_L;oA, CRUZ- ' LW DATE ISSUED: 10/16/2015
q. CA-gW% PHONE NO
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REMOVE (E) WOOD SHAKE, INSTALL (N) OSB PLYWOOD AND
INSTALL (N) LIFETIME COMP. ASPHALT SHINGLES - 30
SQ'S
Sq. Ft Floor Area: I Valuation: $13265
APN Number: 34250021.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECT
/ `/ _•
Issued by:
RE -ROOFS:
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 aU, new materials for
inspection.
Signature of Applican Date:
IG l�
ALL ROOF "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
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.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, an4,25534.
Owner
Civ C.)
Lender's`-Na—me
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
REROOF PERMIT APPLICATION 00131
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
CUPERTI NO (408) 777-3228 • FAX (408) 777-3333 • building cupertino.org
PROJECT ADDRESS G� �% %j'a�
rvQ 1
APN #CIP-10
OWNER NAME�o
PHONE L o
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
FAX
CONTACT NAME ` t j% E PHONE �` E-MAIL
I_ . q ubo s�KIzkY_ ?-AI) A-r-T.J
STREET ADDRESS CITY. STATE, ZIP FAX
10 69 E1)6_11C vHt L� �-�r��h 7 � /F 9�5� �e) - � 3 -f
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME �1 L` K
(
LICENSE NUMBER �y� ")
77 `
LICENSE TYPE
BUS. LIC. #
COMPANY NAME
�0 1 je z �
E -MAI
� �1 � � �T S E � I�� •pan
FAX
� • 1100
STREET ADDRESS c LA GZ� I v
CITY�S�7EAZIP��ZA C,4 $
�,J�
PHONE3333 -
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
t
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF r SFD or Duplex ❑ Multi -Family
STRUCTURE ❑ Commercial
ROOF AREA: //�Q
® �9�/ ' 'r `
VALUATION:
I 3
EXISTING ROOF TYPE: ❑ BUILT-UP ROOF ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER (SPECIFY)
REMOVE /REPLACE 1YES
11NO
IF NO,
I # LAYERS:
PLYWOOD ❑ ''/�" ❑
THICKNESS: 5/8"
PLYWD )KL, OSB
TYPE: 13CDX
PITCH:
12
ROOF
CLASS: A
PROPOSED ROOF TYPE: ❑ BUILT-UP ROOF ASPHALT SHINGLES ❑ WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER
ICC -ES REPORT #
DESCRIPTION OF WORK.7 ( `�71 1 ft
(Z� 1 5qr i 1 Nei C e-(455
By my signature below, I certify to each of the following: I am the property owner or authorized gapt-4 act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Descriptio r< and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construct' ize repre Ives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date: 'C1' f
SUPPL ENTAL INFORMAT IRED
If building is associated with a Hom wrier' �Oiation, 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.
OFFICE USE ONLY
PLAN CHECK TYPE
ROUTING SLIP
OVER-THE-COUNTER
❑ EXPRESS
❑ STANDARD
❑ BUILDING PLAN REVIEW
❑ PLANNING PLAN REVIEW
❑ FIRE DEPT
❑ OTHER:
ReroofApp_2011.doc revised 03/16/11
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