12020028 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21164 GRENOLA DR CONTRACTOR:ROOF ROOFING PERMIT NO: 12020028
OWNER'S NAME: Xlj LEE L AND WU MICHELLE M TRUSTE 5577 VASSAR DR DATE ISSUED:02/07/2012
OWNER'S PHONE: 4085616885 SAN JOSE,CA 95118 PHONE NO:(408)265-9270
13 LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ' ELECT '
-7 PLUMB
69565
License Class Lic.# 1 f— r
MECH RESIDENTIAL COMMERCIAL
Contractor 4t&E eocjl�;�� Datq02
WITH 3-
[hereby affirm that I am JOB DESCRIPTION:INSTALL EXTERIOR BUILT UP ROOF REPLACE licensed r the provisions of Chapter 9 PLY
(commencing with Section 7000)of Division 3 of the Business&Professions CLASS A 21 SQFT
Code and that my license is in full force and effect.
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 for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,,is provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$7000
permit is Issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APN Number:32628058.00 Occupancy Type:
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
indernnifv and keep harmless the City of Cupertino against liabilities,,judgments. PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequenceof the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations pet-the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
Date,,?—_I 7
Signature &Ole Issued by: Date:
0 OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work.and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code) Signature of Applicant Ae Date:
1.tusowner of the property,am exclusively contracting with licensed contractors to 0 F W
construct the project(Sec.7 044,Business&Professions Code). 7
1 hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-Insure for Worker's WAZARDOUS MATERIALS 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 pert-nit is issued. California Health&Safety Code,Sections 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 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.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that In the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will
not eni,.ploy any person in arty manner so xis to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Health&Safet•y Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
wn
forthwith comply with such provisions or this permit shall be deemed revoked. Oer or*"th,rZ,*zd agent:
Date:,..2—
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of cork's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec..3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
*is per the Cupertino Municipal Code,Section
with all tion-point source regulatiI-t ARCHITECT'S DECLARATION
9.18.
1 understand my plans shall be used as public records.
Signature Date
0 1 Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32628058. 00
DATE ISSUED. . . . . . . : 02/07/2012
RECEIPT #. . . . . . . . . : BS000015948
REFERENCE ID # . . . : 12020028
SITE ADDRESS . . . . . : 21164 GRENOLA DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : XU LEE L AND WU MICHELLE M TRU
ADDRESS . . . . . . . . . . : 21164 GRENOLA DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : ROOF ROOFING, INC
CONTRACTOR . . . . . . . : HENRY OLOCKI LIC # 26739
COMPANY . . . . . . . . . . : ROOF ROOFING
ADDRESS . . . . . . . . . . : 5577 VASSAR DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95118
TELEPHONE . . . . . . . . : (408) 265-9270
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 21 .00 294 . 00 0 .00 294 .00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 295 .70 0.00 295 .70 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 414 .70 #3266
---------------
TOTAL RECEIPT 414 .70
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
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/ SUBCONTRACTOR LIST
JOB ADDRESS:, q ,, %Acla1 PERMIT# 0 �'�'�
OWNER'S NAME: Y. PHONE# ('5
GENERAL CONTRACTOR: �. BUSINESS LICENSE#
ADDRESS: �- " Sc� CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/ Carpeting
Linoleum/Wood
Glass/Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
1 .
er/Contractor Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS; 211+64 glenola dr.
rj__,1LA_PN:
DATE: 02/07/2012 REVIEWED BY: bobs.
BP#: VALUATION; $17,000
PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration /Repair
PRIMARY SFD or Du lex PENTAMATION 1 SFDWLROOF
[.ISE; p PERMIT TYPE:
WORK install ex. built up roof replace with 3-ply.
SCOPE
.............
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc.). These ees are based on the erelinina information available and are o!!! an estimate. Contact the De 1t or addn'l info.
FEE ITEMS ,, e'�,:�. £�. a1 �`l 4 p > ' f; FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 2,100 s.f. Re-roof
Suppl.PC Fee: Reg. C _0 hrs $0.00 $294.00 1REROOFRES
PME Plan Check: $0.00
Permit Fee: $0.00
SUppl. Insp. Fee: Reg. C 4T Q,Q 1 hrs $0.00
PINE Unit Fee: $0.00
PME Permit Fee: $0.00
L1
O
Work Without Pen-nit? Yes 0 No $0.00 G
$0.00 Select a Non-Residential
Building or Structure
j!_Tvlh�ti��ri �eC,: I BSEISMICR $1.70 Select an Administrative Item ^ 1
1�'._ SlA y11.1ir:a.issio.n F-_-:e„ IBC,BSC $1.00
SUBTOTALS: $2.70 $294.00 TOTAL FEE: R1j6" .L0
Revised: 1/19/2012
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE-CUPERTINO, CA 95014-3255
CUP (408)777-3228- FAX(408)777-3333 • buildinQe-cupertino.ona
ERTtNC}
PL1E1T ADD S t AM# 3z I f
At, (�
NAME �HiOCr 'Vi��l u E-MAIL
S'T'REET ADDRESS CITY, STATE,ZIP FAX
APPLIC NAME PHO � E-MATL
i -
STREET ADDRESS CIT;STATE, r FAX
OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHTIECT ❑ENGWEER ❑ DEVELOPER ❑TENANT
CO CTOR NAME LICENSE NUMBER LI 5E BUS.LIC.#
/ 75-
///0 ._
CO N E-MAIL FAX
i 1
STREET ADDRESS CITY,STATE,ZIP -7
ARCHITECT/ENGINEERNRME ^ _ LICENSE NUMBER '� BUS.LIC.#
COMPANY NAME E-MAIL. FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF SFD or Duplex ❑ Multi-Family ROOF AREA VALUATION:
STRUCTURE: ❑ Commercial f C
EXISTING ROOF TYPE: �ZBUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY)
REMOVE/REPLACE ?YES IF NO. PLYWOOD ❑ h" ❑ PLYWD ❑ OSB PITCH. ROOF
❑NO #LAYERS: THICKNESS: El 5/8- �-� TYPE: ❑ CDX '12 CLASS: A
PROPOSED ROOF TYPE: BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT#
DESCRIPTION OF ORK
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 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 to building construction. uthonze.representatives of Cupertino tc enter the above-identified proptrt;for inspection purposes.
Signature of Applicant/Agent t!-�� Date, ^
SUPPLEMENTAL DqFORMATION REQUIRED
If building is associated with a Home Owner's Association,provide letter
of approval from HOA. . = Gert xE"�
Provide Planningapproval to ver. if there an restrictions. OEM
u =� 'g �-'
PP verify Ys � _ Q. c PLe�NREPIEW
Provide copy of Manufacturer's Installation Specifications. t '�~
_LWOvide signed copy of Cupertino's Tear-Off Policy.
ReroofApp_2011.doc revised 03/02/11