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12030116 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10955 NORTI ISEAL SQ CONTRACTOR:POUR SEASONS ROOTING PERDI I'1'NO: 12030116
OWNER'S NAME: LYDIA BALANO TRUSTEE PO BOX 1668 DATE ISSUED:0322/2012•
OWNER'S PRONE: SAN JOSE.CA 95109 PHONE NO:(408)278-0330
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG r ELECT r' PLUMB rf
License Class C-11 Lie.0 (A Z10p r r r
MECH RESIDENTIAL COMMERCIALContractor FAMr SCISs,.t i..e Date
1 hereby affirm that I am licensedunder the provisions of Chapter .JOB DESCRIPTION:SFDWL REROOF,.13 SO,TEAR OF17 EXISTING CAL-SI'IARE
(commencing with Section 7000)of Division 3 of the Business&Professions ROOFING SYSTEM,INSTALL 30N FELT UNDERLAYMENTS AND
Code and that me license is in full force and effect. INSTALL GAP GRAND CANYON SHINGLES,
1 hereby affirm under penally of perjury one Of the followingtwo 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 for which this permit is issued.
(have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of Ole work Ion which Ihis Sq.Fl Fluor Area: Vnluationi:$7000
permit is issued.
APPLICANT'CERT'IFICATTON G71L• APN Number:.31640021.00 Occupancy Type
I certify that have read this application and stale that the above information is
correct. Iagree to comply with all city:and county ordinances and state Imes relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES 1F WORK IS NOT STARTED
indemnify and keep harmless.tire City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply• 1$O DAYS M LAST CALLED INSPECTION.
withal)non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Is ed 7/7 LL Date:
Signature Date Z
❑ 'NF:R-BUILDER DECLARATION
RF-ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Law far 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
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the stricture is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVER 1, .S TO IDC CLASS"A"OR BEEPER
hereby affirmu oder penalty of perj try one of the rolluwi ng three
declarations:,
I have and will maintain a Certificate of Consent to set Gins-ure for Worker's IIA'LARDOUS htAT'ERIAI.S DISCLOSURE
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 Ilea th&Safety Code.See tions 25505,25533,and 25534. 1 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 Ilealth&
Safely Code,Section 25532(x)should I store or handle harrrdous material.
Section 3700 of the labor Code,for the performance of the work for which This Addiliomdly,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Ray Area Air Quality Management District I will
I certify that in the performance of Ore 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
iz• nr•'
a
become subject to the Workers Compensation provisions of the Labor Code,I mOwner ora
ust 1u
lonhwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CER'fl FIG\'PION
.ONSIRUC`I'ION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affim (here is a construction lending agency for the performance of work's
correct. I agree to comply with all city and county ordinances and stale 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
indenmify 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 ARCIII'I'I:CI'75 DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used,is public records.
Signature Dale Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 15 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31640021 . 00
DATE ISSUED. . . . . . . : 03/22/2012
RECEIPT 4. . . . . . . . . : BS000016333
REFERENCE ID # . . . : 12030116
SITE ADDRESS . . . . . : 10.955 NORTHSEAL SQ
SUBDIVISION . . . . ... .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : LYDIA BALANO TRUSTEE
ADDRESS . . . . . . . . . . : PO BOX 1244
CITY/STATE/ZIP . . . : CUPERTINO, CA 95015
RECEIVED FROM . . . . : FOUR SEASONS ROOFIN
CONTRACTOR DIAZ, ALFRED LIC # 21323
COMPANY . . . . . . . . . . : FOUR SEASONS ROOFING
ADDRESS . . . . . . . . . . : PO BOX 1668 -
CITY/STATE/ZIP . . . : SAN JOSE, CA 95109
TELEPHONE . . . . . . . . : (408) 278-0330
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- --------— --------— ---------- ---------- ----------
1BCBSC VALUATION 7, 000 . 00 1. 00 0 . 00 1. 00 0 . 00
1BSEISMICR VALUATION 7, 000 . 00 0 . 70 0. 00 0. 70 0. 00
1REROOFRES SQ FEET 13 . 00 182 . 00 0 . 00 182 . 00 0 .00
TOTAL PERMIT 183 . 70 0. 00 183 .70 0 . 00
VOICE ID. DESCRIPTION VOICE ID DESCRIPTION
----- ----------- -------- ----------------------------
309
------------------------
309 EXTERIOR LATH .311 SCRATCH COAT
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
04: 18, 4089960226 NORTHPOINT M02
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CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION I
Im ADDRESS: 10955 Northseal Sq. DA'Z'E: 03/22/2012 REVIEWED BY: Sean
APN: BP#: "VALUATION: $7,000
•PERMITTYPE: Minor Building Permit PLAN CIIECK TYPE; Re-roof
PRIMA RI SFD or Duplex PF,NTAMATION 1SFDWLR00F
USE: PERMIT TYPE:
WORK Tear-off existing cal-shake roofing system, install 30#felt underla ments and install GAF Grand
SCOPE Canyon Shingles (1300 so, Color: Stonewood.
FEEID ROOFAREA
(s.f.
iREROOFFRES 1,300
ifech. Plan Check Plumb. flan Check Elec.Plan Check
bliu;ir. Permit Fee: Plumb. Permit Fee: Flee. Permit Fee:
t.'Ither'Itech.hap. Other Phnnh Insp. Other Elec.11151). Li
He<:h,Imp. Fee: Plumb. Insp.Pee: Fier./m1). Fa:a:
NOTE: This esvitrut(e tloes not inchetle fees due to other Departments(i.e. Planning, Public Works, fire,Sanitup'Sem'er District.Sch(lol
District,etc.). These feev are baser/on the prefinjinan information available and are oudw,un esdnatte. Contact the De ( or addn'I in o.
FEE ITEMS (Fee Resolution 11-053 F_iI7/1111) FEE QTY/FEE MISC ITEMS
Plan Cheek Fee:
Suppl. PCFee
Phnnh.lHech,:'F.lec
Permit Fee: $182.00
Suppl. hasp Fee
Pl t ran l.;Ar/e(.h.:Llec
Pltmth_!:bieclt.:h'ler.Permit Fere:
Construction Tax:
Aelministralive Fee:
Work Without Permit? O Yes C) No $0.00
A(haneed Planning Fees:
Trove(Documentation Fees:
Saone Motion Fee: iBSFISAIICR $0.70 Select an Administrative Item
UI(le Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: 1 $183.70 $0.00 TOTAL FEE: $183.70
Revised: 1/19/2012
REROOF PERMIT APPLICATION 11
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION �3
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255'
CUPERTINO (408)777-3228'• FAX(408)777-3333•buildinG(lilcuoertino.om I
PROJECT ADDRESS. APN a 0;3� �
OWNER NAME Pito I EMAIL
0ADDRESS CIN,SFA ZIP I FAX
aCUNTACT NAME PHONE EMAIL
1•� do z.a�e-s .o
SIAELT ADDRESS CIN,STATE,�ZIP t' FAX
o Sose Cw. S
❑OWNER ❑-OWNER-BUTLOER ❑ OWNER AGENT CONTRACTOR ❑CON RAC Int AGENT ❑ ARCHITECT ❑[ GINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSETYPE I a BUS.UC.M 3 3
COMPANY NAME E-MAIL t a FAX
STREET ADDRESS CRY,STATE ZIP PHONE
�Z � A. 5
ARCHRECTIENGLNEERNAME - LICENSEN•UMBER t BUS.LIC.M
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
y�
USE OF ❑ SFD or Duplex U[ Multi-Family ROOF AREA:- 'VALUATION:
SIRULTURE: ❑ Commercial /\ S
EXLSTING ROOF TYPE: ❑BUILT-UPRWF ❑ASPHALT SHINGLES 11 WOOD SHAI:P-S ❑WOODSHINOT-ES OTHER(SPECIFY) A�L S^
A SRA
REMOVE/REPLACE jp
/❑_ N0 qW NO0,OS : ROOF. W ❑ D Q }' A
PROPOSED ROOF TYPE: ❑BUILT-UPROOF XASPHALT SHINGLES C1 WOOD SHARES 11 WOOD SHINES ❑
GLOTHER ICC-FS REPORTY
DESCR1PIION OF WORK: -
_ _
i n s4,e,I i 3 * s G
�n Co or t1'
By my signature below,I certify to each of the following: I am the property owner or authorized agent m act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating Io building cons 'on.[ thou resentatives of Cupertino to enter the above-identified property for inspection purposes.
Signanue of Applicant/Agent: t• .I•' Date:
SUPPLEMENTALINFORMATIONRE ED OFFlCE USF.ONLY
_If building is associated With a Home Owners Association,provide letter `'F"'+PLANCHECK'rYPE •t'}`` ' ' ROUTING SLIP
c".iii Bt7 ./.LLTµ .
of approval from HOA. :. .
.❑'-OVER•TBF.COUNTER- ❑ BUILDING PL.VI REVIEW
Provide Planning approval to verify if them any restrictions.
t'' )•;n$`v rt7!}; f;:, ` t '
❑ ©LPRLSS: ❑ PLANNING PLAN REVIEW
_Provide copy of Manufacturer's Installation Specifications. t I t
❑,STANDARD ❑ FIRE DEPT'
}'I ••SFO -
Provide signed copy of Cupertino's Tear-Off Policy. ❑. OTHER:
- i
RerogJ App_2011.doc revised 03116/11
