11120093 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 6125 BOLLINGER RD CONTRACTOR:COSMOS ROOFING PERMIT NO: 11120093
OWNER'S NAME: PETERSON KURT 999 COMMERCIAL ST STE 105 DATE ISSUED: 12/16/2011
OWNER'S PHONE: 5105528217 PALO ALTO,CA 94303 PHONE.NO:(650)969-7663
1k LICENSED CONTRACTOR'S DECLARATION r r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class_ Lic.N 7Sz 5 Lf 4 1
MECH r' r r
RESIDENTIAL COMMERCIAL
Contractor nM OS 1 14411 Date--)-?f::// 1
1 hereby affirm that I am licensed under`l4e provisions of Chapter 9 JOB DESCRIPTION:RE-ROOF REPLACE TAR AND GRAVEL WITH TAR AND
(commencing with Section 7000)of Division 3 of the Business&Professions GRAVEL
Code and that my license Is in full force and effect. ROOF CLASS A 25SQFT
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 fog 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:$11750
permit is issued.
APPLICANT CERTIFICATION APN Number:37538010.00 Occupancy Type:
1 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 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 re 'ons per the Cupertino Municipal Code,Section
9.18.
9.18, u Date 1 1 I) Issued b).�/�� Dater/Z ll/f
Signor13OWNER-BUILDER DECLARATION
RE-ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material berg 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,
Z1Business&Professions Code) Signature of Applicant Date: 12-
1,
,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
I 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 Cade,Sections 25.505,25533,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,1 must Owner or a ed age
forthwith comply with such provisions or this permit shall be deemed revoked. Date: I Z 1 b 11
APPLICANT CERTIFICATION ONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.1 agree to comply with all city and county ordinances and state laws relating for which this 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
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 37538010. 00
DATE ISSUED. . . . . . . : 12/16/2011
RECEIPT #. . . . . . . . . : BS000015582
REFERENCE ID # . . . : 11120093
SITE ADDRESS . . . . . : 6125 BOLLINGER RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PETERSON KURT
ADDRESS . . . . . . . . . . : 34872 HERRINGBONE WAY
CITY/STATE/ZIP . . . : UNION CITY, CA 94587
RECEIVED FROM . . . . : JEFF RAINEY
CONTRACTOR . . . . . . . : COSMOS, RICHARD LIC # 18844
COMPANY . . . . . . . . . . : COSMOS ROOFING
ADDRESS . . . . . . . . . . : 999 COMMERCIAL ST STE 105
CITY/STATE/ZIP . . . : PALO ALTO, CA 94303
TELEPHONE . . . . . . . . : (650) 969-7663
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BCBSC VALUATION 11,750 .00 1 .00 0 .00 1 .00 0. 00
1BSEISMICO VALUATION 11,750.00 2 .47 0. 00 2 .47 0. 00
1REROOFCOM SQUARES 25. 00 359.00 0 . 00 359.00 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 362 .47 0. 00 362 .47 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 362.47 VISA
---------------
TOTAL RECEIPT 362.47
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
309 EXTERIOR LATH 311 SCRATCH COAT
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
/l1a6) U93
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228•FAX(408)777-3333•buildina(d),cuoertino.ora
PROTECT ADDRESS APNN C>10
OWNER NAME N PH NE gZ1 EMAIL
URT �7eTt ��D • SZ17
STREET ADDRESS / (� ( 1/ LTL i2`1 CITY, STATE,ZR71,.J0 r 9 SQI q FAX
CONTACT NAME WAMA 0 COSMOS ROOFING / PHONE 650-969-7663 E-MAIL
STREET ADDRESS 999 COMMERCIAL STREET #105 CITY,STATE, ZIP PALO ALTO, CA 94303 FAX 650-485-2314
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT EI CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSETYPE BUS.LIC4
RICH COSMOS 785441 C39
COMPANY NAME COSMOS ROOFING E-MAIL FAX 650-485-2314
STREET ADDRESS 999 COMMERCIAL STREET 4105 CITY,STATO,ZIP PALO ALTO, CA 94303 PHONE 650-969-7663
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC,P
COMPANY NAME E-MAIL FAX
E
STREET ADDRESS CITY,STATE,ZIP PHONE
USF. OF ❑ SFD or Duplex ❑ Multi-Family ROOFAREA. VALUATION:
STRUCTURE, ® Commercial -Z- !5 CD 51 I I /5 D —
EXISTING ROOF TYPE::,// 9IBUILT-UPROOF 13 ASPHALT SHINGLES ❑WOOD SHAKES ❑WOODSHINGLES ❑OTHER(SPECIFY)
REMOVEIREPLACE Il1YES LYWOOD E3 H" 11 PLYWD 13 OSB PITCH: 1 ROOF
25.12 N ASS
A❑ n
PROPOSED ROOF TYPE: BUILT-UPROOF ❑ASPHALT SHINGLES 13 WOOD SHAKES 11 WOOD SHINGLES 13 OTHER ICC-ES REPORTS
DESCRIPTION OF WORK: / f 61Z^-OrI
_ATA�Z d- 62 AOL- l . Cc. 4s 5 A
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 1 have provided is correct. I have read the Description of Work and verify it is accurate. 1 agree to comply withal]applicable local
ordinances and state laws relating to building construction. 'ze representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: 12- 1& 1
SUPPLE NTAL INFORMAT UIRED OFFICE USE ONLY
_ If building is associated with a Ho en's Association,provide letter ,,,. PLAN CHECK TYPE ROOTING SLIP
of approval from HOA. Ll-t`iv11THE-COUNTERBu�LAN REVIEW
Provide Planning approval to verify if there any restrictions. ❑ EXPRESS ❑ PLANNING PLAN REVIEW
Provide copy of Manufacturer's Installation Specifications. ❑ STANDARD ❑ FIRE DEPT
Provide signed copy of Cupertino's Tear-Off Policy. I ❑ OTHER:
ReroofApp_101 l.docrevised 03116111
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 6125 bollinger rd. DATE: 12115/2011 REVIEWED BY: bobs.
APN: BP#: *VALUATION: $11,750
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building PENTAMATION 1COMMLROOF
USE: PERMIT TYPE:
WORK re lace tar and gravel with tar and gravel roof.
SCOPE
Mei:h. Plan CiwAc Plumb. Finn Chsnk Elec.1114u Checd.
Much Penrh Fe;e: Plumh. PVoral Fce' -lec. Permh F w:
Once, It vll.Ir;sP- Other 1'heeb Lr,cp. Ocher kh'x lasp. Li
Ancef.Ing). FeePlmah.Imp,Fee: Elec.lnsn.Feer
NOTE: This estimate does not include fees due to other Departments fl.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District etc. . Thesefees are based on the relhtina In ormallon available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolation 11-053 Eli: 71L/1_U FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.002,500 s.f. Re-roof
Suppl. PC Fee: (E) Reg. 0 OT 0.0 hrs $0.00 $359.001 IREROOFCOM
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee.e Reg. 0 OT 0,0 hrs $0.00
PME Unit Fee: $0.001 1
PME Permit Fee: $0.00
Colwrac7ion T .e:
Administrative Fee: O
Work Without Permit? 0 Yes (E) No $0.00 0
Advanced Plannine Fee: $0.00 Select a Non-Residential t'
T'rin'e/Docemenlcrrinu Fees: Building or Structure 0
Strong,Motion Fee: IBSEISMICO $2.47 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $3.47 $359.00 TOTAL FEE: $362.47
Revised: 12/04/2011
Dec 15 11 10: 54a Cosmos Roofing (650) 969-9905 P. 2
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Date
2011-72-1511:57 6509699905 Paae 2/2