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11050238 CITY OF CUPERTINO BUILDING PERMIT BUILDING,ADDRESS: 22578 LAZY OAK CT CONTRACTOR: DRAEGER PERMIT NO: 11050238 CONSTRUCTION INC OWNER'S NAME: JENNIFER MORI 605 COMMERCIAL ST DATE ISSUED:08/22/2011 OWNER'S PHONE: SAN JOSE, CA 95112 PHONE NO:(408)536-0420 ❑ LICENSED CONTRACTOR'S DECLARATIONr— BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class 3,ri Lic.# o I— MECH RESIDENTIAL COMMERCIAL Contracto a - 6,45. Date 4riz= t/ 1 herebyaffirm t at 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RE-ROOF 10.2 SQ-1/2"PLYWOOD,TPO OVERLAY WITH 2 P P LAYER FR-10 BARRIER (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate ofconsent 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. Sq.Ft Floor Area: Valuation:$375 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the worAfwhich this APN Number:34232005.00 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 WITHIN 180 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 DAYS M LAST CALLED IN 77 N. 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. Additional) , e plicant understands and will comply Issued by: Date: with all non-point source regul ons the Cupertino Municipal Code,Section 9 I8. RE-ROOFS: Signature Date 2 _ y All roofs shall be inspected prior to any roof ng material being installed. If a roof is installed without first obtaining an insp i ,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applic Date: 1 hereby affirm that I am exempt from the Contractor's License Law for one of � 5� t/ 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 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 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,Sect' ns 25505,25533,and 25C43. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agDate:/` f permit is issued. 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 CONSTRUCTION LENDING AGENCY Compensation laws of California. If,after making this certificate of exemption,1 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 ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, 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 CITY OF CUPERTINO 3 ITEMS OF 15 PERMIT RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 34232005 . 00 DATE ISSUED. . . . . . . : 08/22/2011 RECEIPT # . • . . • • • • • : BS000014519 REFERENCE ID # . . . : 11050238 SITE ADDRESS . . . . . : 22578 LAZY OAK CT SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : JENNIFER MORI ADDRESS . . . . . . . . . . : 22578 LAZY OAK CT CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : DRAEGER CONST. CONTRACTOR . . . . . . . : DRAEGER, JOHN EDWARD LIC # 21895 COMPANY . . . . . . . . . . : DRAEGER CONSTRUCTION INC ADDRESS . . . . . . . . . . : 605 COMMERCIAL ST CITY/STATE/ZIP . . . : SAN JOSE, CA 95112 TELEPHONE . . . . . . . . : (408) 536-0420 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 375 . 00 1 .00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 375 . 00 0 . 50 0 . 00 0 .50 0 . 00 1REROOFRES SQ FEET 10 . 00 140 . 00 0 . 00 140 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 141 .50 0 . 00 141 .50 0 . 00 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 REROOF PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333•buildina ancuperiino.orn CUPERTINO 2-25) $ __Y pvnTrrr ennvrcc �Z� 6 4 u'� I APN# 2Z5�S� 578 ZZ --Z? � - -z2- ' USS OWNEP,NANS. C J en n I+/ A I PHO l � (' �� % E-MAIL STREET ADDRESSFAX ZU-70 OZ AP �t � PHONE E-MAIL STAEE�DRF,$ FAX S P K ST STATE ZIP pp (k) f ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGMEMR ❑ DEVELOPER ❑TENANT C CrQR N LI NUMB LrI TYPE BUS.LIC.# Vl G� E-MAIL FAX STREET�� p� �� Jl� C STATE o se CiA I -ZZ / ARCHITECT/ENGII-ZEER NAME LICENSE14 BUS.LIC.# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE I USE OF D or Duplex ❑ Multi-Family /ROOF AREA: VAT tre-n / 2� Zi -9 I STRUCTURE: ❑ Commercial S EXISTING ROOF TYPE: Un.T-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY) REMOVE/REPLACE ❑YES IF NO, PLYWOOD W' ❑ _ PLYWD ❑ OSB PITCH: ROOF 5KNO #LAYERS THICKNESS: ❑ 5/S" TYPE: IZ CDX '12 CLASS: A PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES OTHER ICC-ES REPORT# DESCRIPTION OF WORK r Ely "A-.V By my signature below,I certify to each of the follo ng: I the property owne au rized agent to act on the property owner's behalf. I have read this application and the information I have proNC'd i rre . have read the Des p'on of ork and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to buildi c s on. I au ' ere entatives Cupertino tc enter the above-ide ' Ied prope y for inspection purposes. Signature of Applicant/Agent: Date: l SUPPLEMENTAL INFORMATION REQUIRED `wt .�� _If building is associated with a Home Owner's Association,provide letter p �`- c4.smpnY KF"' of approval from HOA. — 4 ��O�R'�_DI�_i�'TF,R� BUII.�IlVG PIAN REVIEW:�. 'yyi"`rbtl_rr „aF,'.-_'. � ,�f.i- 4 t _Provide Planning approval to verify if there any restrictions. _ - ItESS PL7�2INATG PLANREVIESi' Provide copy of Manufacturer's Installation Specifications. 4 i rovide signed copy of Cupertino's Tear-Off Policy. 4 'rte ReroofApp_2011.doc revised 03/02/11