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11050282 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22671 QUEENS OAK CT CONTRACTOR:DRAEGER PERMIT NO: 11050282 CONSTRUCTION INC OWNER'S NAME: RAMACHANDRAN, VIJAY 605 COMMERCIAL ST DATE ISSUED:08/22/2011 OWNER'S PHONE: SAN JOSE, CA 95112 PHONE NO:(408)536-0420 ❑ LICENSED CONTRACTOR'S DECLARATIONI— BUf[.DING PERMIT INFO: BLDG ELECT PLUMB License Class__(7 _ Lia# 1 �l MECH RESIDENTIAL COMMERCIAL Contractord/ Date Z JOB DESCRIPTION: RE-ROOF 10.4 SQ-1/2"PLYWOOD,TPO OVERLAY WITH 2 1 hereby affirm�amsed under the provisions of Chapter 9 LAYER FR-10 BARRIER (commencing with Section 7000)of Division 3 ofthe 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 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:$375 1 have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 ofthe Labor Code,for the performance of the work for which this APN Number:34232065.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 9,0 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 OM LAST CALLED INSPECTI N. indemnify and keep harmless the City of Cu - . o against liabilities,judgments, costs,and expenses which may accrue a 'nst id City in consequence of the eranting of this permit. Additional , e,a icant understands and will comply Issued by: Date: with all non-point source regul ons pe - ie Cupertino Municipal Code,Section 9.18 C' RE-ROOFS: Signal _ Date_© �S" _�_ All roofs shall be inspected prior to any roofi material being installed. If a roof is installed without first obtaining an inspe on,,11 agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Appy D S I hereby affirm that 1 am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER L as owner ofthe 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 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 ofthe Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1 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,Sec ons 25505,25533,an7255 tSection 3700 ofthe Labor Code,for the performance of the work for which this Owner or authorized ager l Date: 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 Compensation laws of California. If,after making this certificate ofexemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions ofthe 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION costs,and expenses which may accrue against said City in consequence ofthe 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 . . . . . . . . : 34232065 . 00 DATE ISSUED. . . . . . . : 08/22/2011 RECEIPT #. . . . . . . . . : BS000014524 REFERENCE ID # . . . : 11050282 SITE ADDRESS . . . . . : 22671 QUEENS OAK CT SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : RAMACHANDRAN, VIJAY ADDRESS . . . . . . . . . . : 22671 QUEENS OAK CT CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1023 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 CUPERTINO (408)777-3228• FAX(408)777-3333 • building c--cuper'rino.org Z-z( II _ DS C� Zga� PDnmc Annvrec 6� I APN# 21R:a►r,ilGtChGt n� " 3,4 3Z dP S G �n�i E-MAIL.i � ADDRESS DRESS 0 J �1TY, STATE ( FAX AP CANT N '4 PHONE �_ EMAIL SD 5 CUY,STATE, ZIP ?' FAX ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT COCT()RNAME LI NUMB LIT$ E BUS.LIC.# bt GC ` 5 E-MAIL FAX SIR ST,/yp� p{� .(tr/L 7 A �-"' 12— ARCHITEECCT/ENG=R NAME LICENSE BUS.LIC.# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF _SFD or Duplex ❑ Multi-Family (¢F `y1 AjtTI ,A: VALUAnN- .G 1 STRUCTURE: ❑ Commercial (/ EXISTING ROOF TYPE: UILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY) REMOVE/REPLACE ❑YES IF NO. PLYWOOD JZ W, ❑ PLYWD ❑ OSB PITCH: ROOF 5KNO I #LAYERS: THICKNESS: ❑ 5/8" TYPE: W CDX '1 CLASS: A PROPOSED ROOF TYPE: ❑B=-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ;gOTr7ER ICC-ES REPORT# DESCRIPTION OF WORK-- By ORKBy my signature below,I certify to each of the foll g: I am the prop r or authorized agent to act on the property owner's be f. I have read this ap?lication and the information I have provided' rrect. I have re a Descrip ion of Work and verify it is accurate. I gree to com with all applicable local v ordinances and state laws relating to build' tructi . I auth a represen "ves of Cupertino tc enter the a ove-' ?fled prop�for inspection purposes. Signature of Applicant/Agent Date: G (3 SUPPLE ORMATION REQ D �"y r ` ,° e ,. _ rim ftW-0' If building is associated with a Home Owner's Association,provide letter �--- - P -' ��•��,-a- ._,_-__ �.��otl�NcsL� � _ of approval from HOA. z " PP =OYER COIIIF � BXD1DRVG P,vAN•REVtEW r .-� --iJt.aT�2z^.�+a � n.e.4i.� �..+.y h.•ay,-C 'w. Y .T� tM1 —Provide Planning approval to verify if there any restrictions. �" 'I �` 5 ' AES6 uPVA`AIrIIiIGYLz1TIItES'IEW:_ _Prov copy of Manufacturer's Installation Specifications. EIR1rDEE'I' _P✓ rovide signed copy of Cu ertino's Tear-Off Policy. Reroofflpp_2011.doc revised 03/02/11