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10100009 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 6031 BOLLINGER RD CONTRACTOR:COSMOS ROOFING PERMIT NO: 10100009 OWNER'S NAME: ANN&SAM FONG 1901 OLD MIDDLEFIELD WAY STE 22 DATE ISSUED: 10/01/2010 'NER'S PHONE: 4082576306 MOUNTAIN VIEW,CA 94043 PHONE NO:(650)969-7663 C LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class [' Lic.# ' S RE-ROOF 25 SQUARES,TEAR OFF EXISTING TAR AND GRAVEL NO RESHEET INSTALL 4PLY CLASS A Contractor �"," r�! Date i0l, I hereby affirm that I am licensed un r the provisions of Cha ter 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 declaraticns: 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. Sq.Ft Floor Area: Valuation:$10535 1 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 APN Number:37538003.00 Occupancy Type: permit is issued. a p y yp APPLICANT CERTIFICATION Znmation I certify that I have read this application and state that the above 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 ente upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM 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: �y�, Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature e f r "' 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 all new materials for inspection. OWNER-BUILDER DECLARATION Signature of Applicant: r� l I hereby affirm that I am exempt from the Contractor's License Law for or a of the following two reasons: ALL RO OVE TO LASS"A"OR BETTER 1,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) 1,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. I 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 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: ate: permit is issued. I certify that in the performance of the work for which this permit is issued,I$h III 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 rel ting to building construction,and hereby authorize representatives of this city to ent;r upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION i-�'-mnify and keep harmless the City of Cupertino against liabilities,judgment S, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. .ing of this permit.Additionally,the applicant understands and will compl) with all non-point source regulations per the Cupertino Municipal Code,Sectio i Licensed Professional 9.18. Signature Date CITY CF CUPERTINO 3 ITEMS OF 8 PERM T RECEIPT OPERATOR: SylviaM COPY # 1 Sec: Twp: Rng: Sub: Falk: Lot: APN . . . . . . . . : = 7538003 . 00 DATE ISSUED. . . . . . . : 1.0/01/2010 RECEIPT #. . . . . . . . . DS000011613 REFERENCE ID # . . . -.0100009 SITE ADDRESS . . . . . : 6031 BOLLINGER RD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER ANN & SAM FONG ADDRESS 6031 BOLLINGER RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : .JEFF RAINEY CONTRACTOR COSMOS, RICHARD LIC # 18844 COMPANY 1"-OSMOS ROOFING ADDRESS L901 OLD MIDDLEFIELD WAY STE 2 CITY/STATE/ZIP . . . : 140UNTAIN VIEW, CA 94043 TELEPHONE (650) 969-7663 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ------ 1BCBSC VALUATION 10, 535 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 10, 535 . 00 1.10 0 . 00 1 . 10 0 . 00 1REROOFRES SQ FEET 25 .00 325 . 00 0 . 00 325 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 327 . 10 0 . 00 327 . 10 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 538 . 60 VISA --------------- TOTAL RECEIPT 538 . 60 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ----------- 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 604 ROOF IN-PROGRESS 605 FINAL REROOF INPUT Resources Energy IAO/Health M.Indoor Air Qualityand Finishes 1.Use Low/No-VOC Paint 1 IAO/Health pts y=yes 0 2.Use Low VOC,Water-Based Wood Finishes 2 IAQ/Health pts y=yes 0 3.Use Low/No VOC Adhesives 3 IAQ/Health pts y=yes 0 4,Use Salvaged Materials for Interior Finishes 3 Resource pts y=yes 0 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 61AO/Health pts y=yes 0 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/Health pts y=yes 0 7.Seal all Exposed Particleboard or MDF 4 IAQ/Health pts y=yes 0 8.Use FSC Certified Materials for Interior Finish 4 Resource pts y=yes 0 9.Use Finger-Jointed or Recycled-Content Trim 1 Resource pts y=yes 0 10.Install Whole House Vacuum System 3 IAQ/Health pts y=yes 0 ' I I I N.Flooring 1.Select FSC Certified Wood Flooring 8 Resource pts y=yes 0 2.Use Rapidly Renewable Flooring Materials 4 Resource pts y=yes 0 3.Use Recycled Content Ceramic Tiles 4 Resource pts y=yes 0 4.Install Natural Linoleum in Place of Vinyl 5 IAQ/Health pts y=yes 0 5.Use Exposed Concrete as Finished Floor 4 Resource pts y=yes 0 6.Install Recycled Content Carpet with Low VOCs 4 Resource pts y=yes 0 ' I 1 I Total Points 1 1401 130 57 Total Points Project Received: 01 0 0 G:data/progsi)reenbuildingguidelines/remodelers/greenpointsfinal2./4,petected.x1s CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: DATE: REVIEWED BY: APN: BP#: *VALUATION: $10,535 R�PERMITTYPE: Minor Building Permit FLAN CHECK TYPE: Re-roof PRIMARYSFD or Duplex ; i PENTAMATION 1SFDWLR00F USE: TL U( f� t`ti 1-=t: PERMIT TYPE: WORK SCOPE FEE ID RCOF AREA s.f. 1REROOFFRES 2,500 t L1:�c Ir. F fare t'rr<ick" P , it Fct F-1 I Li M9 /i I'C" NOTE: Theseees are based on the preliminaryin ormation available and are onlyan estimate. Contact the De t or addn'l info. FEE ITEMS(Fee Resolytion 09-051 Eff. 7:%1i10j FEE QTY/FEE MISC ITEMS Man C 11ccA" Vuc slippl. i'(..`l""C' PTlirrzh ""11�'�I1."J1c{" I'iazl <`/Jcf:li: Permit Fee: $325.00 Sral:,p/. I11s11 Fcc Uilii Fee: 1'ltstozll./ale�t11.:1i?ec I'clII01 Fee, t'onswilc lion Tax 1c:c�ttstitar; !i c't'ir�11Fc'�': Work Without Permit? 0 Yes No $0.00 -TI-ove! Fccc'.s': Strong Motion Fee: 1BSEISMICR $1.05 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: 9327.05 $0.00 TOTAL FEE: $327.05 Revised: 9/29/2010 tTY Of CITY OF CUPERTINO REROOF ZEN C U P S RT I N O PERMIT APPLICATION APN # Date: / �� 31 S' 3� �3 Building Address: � 60 -51 _t'2-'D Owner's Name: f Phone #: 0,q HOA: Yes ❑ No 0 If yes, provide letter from HOA 7-5 ? - 1) 506 Contractor: Phone #: 650-793-5012 COSMOS ROOFING 1901 OLD MIDDLEFIELD WY #22, MENLO PARK, CA 94043 Fax #: 650-969-9905 Cupertino Business License #: Contractor License #: 785441 Type of Roof Covering: Existing: Proposed: ❑ Built-Up Roof ❑ Built-Up roof ❑ Asphalt Shingles ❑ Asphalt Shingles ❑ Wood Shakes ❑ Wood Shakes ❑ Wood Shingles ❑ Wood Shingles 9( Other (Specify) iZ p1-0 f ?t Other (Specify) 7,t2- ,f- C3 R-A J0_ Number of existing coverings O AJ E_ ❑ Provide I.C.C.E.S. Report # �t, To be Removed ❑ Provide Mfgr. Installation Specs. Job Description: �� iz c ;-I 5;7, v� jr G _ G ►W-6 s Hct--7 . `--f �� ,` 'T1�-�Z �1�J G S�j Residential X❑ Commercial ❑ Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if Green Building Checklist & attach it to the application or if there are any restrictions: ❑ applicable, include in plan set & the sheet index. Valuation: d /6)) 5S-5 6) 5S-5 I Have Read Understand and Will Comply with Cupertino's Tear-Off Policy: Signat e Revised 02/05/09