11050290 CITY OF CUPERTINO BUILDING PERMIT
CONTRACTOR:DRAEGER PERMIT NO: 11050290
BUILDING ADDRESS: 22653 QUEENS OAK CT
CONSTRUCTION INC
605 COMMERCIAL ST DATE ISSUED:08/22/2011
OWNER'S NAME: SURESH MASURKAR& LATA
BHANDARKAR
SAN JOSE,CA 95112 PHONE NO:(408)536-0420
OWNER'S PHONE:
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class ` Lie. Q MECH RESIDENTIAL COMMERCIAL
n�
Contractor�� f� el Date G' �'
JOB DESCRIPTION: RE-ROOF 9.3 SQ-1/2"PLYWOOD,TPO OVERLAY WITH 2
hereby affirm t at I am licensed under the provisions of Chapter 9 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.
1 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 Valuation:$375
performance of the work for which this permit is issued. Sq.Ft Floor Area:
1 have and\N ill 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:34232062.00 Occupancy Type:
permit is issued. I
APPLICANT CERTIFICATION l is EXPIRES IF WORK IS NOT STARTED
I certify that I have read this application and state that the above infornation PERMIT
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 180 DAY FR M LAST CALLED INSPE TI N.
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs.and expenses which may accrue against said City in consequence of the Issued by: Date:
granting of this permit. Additionally applicant understands and will comply
with all non-point source regula s er the Cu no M nicipal Code,Section
9.18. RE-ROOFS:
Signature _Date All roofs shall be inspected prior to any roofin erial being installed. if a roof is
installed without first obtaining an inspec ' gree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION ate: l
Signature of Applicant:
hereby affirm that 1 am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
the following two reasons:
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) HAZARDOUS MATERIALS DISCLOSURE
1.as owner of the property.am exclusively contracting with licensed contractors to
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
the Bay
rea Air
Compensation,as provided for by Section 3700 of the Labor Code,for the w istrict I
llcontaminants
main maintain compliance with ned ythe Cupertino Munniic pal Code,Chapter uality Management D.12 and
performance of the work for which this permit is issued. the Health&Safety Code,Seqions 255 9 5,25533,an 34.
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 Owner or authorized age • 1C1 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 CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,l
. lending become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm
that there is a this permit isoss tructionued 3097 Civ
the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for 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
indenmify 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
PERMIT RECEIPT OPERATOR: SylviaM
3 ITEMS OF 18 COPY # 1
Sec : Twp : Rng : Sub: Blk: Lot :
APN 34232062 . 00
DATE ISSUED . • -
08/22/2011
RECEIPT # . . . . . . . . . gS000014521
" " � 11050290
REFERENCE ID # • • •
SITE ADDRESS 22653 QUEENS OAK CT
SUBDIVISION • • - " . : CUPERTINO
CITY • •
IMPACT AREA . . . . . .
OWNER SURESH MASURKAR & LATA BHANDAR
ADDRESS 22653 QUEENS 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
UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL-
FEE ID --
- - - - - - - --- -- 0 . 00
- -- -- --- - - 1 . 00
- - - - - --- - - -- -- - - 375 . 00 1 . 00 0 . 00 0 . 00
1BCBSC VALUATION 0 . 50 0 . 00 0 . 50
1BSEISMICR VALUATION 375 . 00 9 . 0 . 00
00 126 . 00 0 . 00 126 . 00
1REROOFRES SQ FEET - -- ---- --- ----------
127 . 50- -- -- - - -- - 0 . 00 127 . 50 0 . 00
TOTAL PERMIT
AMOUNT REFERENCE NUMBER
METHOD OF PAYMENT -------- - ---
---
CHECK -- - - --- 765 . 00 0753
TOTAL RECEIPT 765 . 00
- - VOICE ID DESCRIPTION
VOICE ID
DESCRIPTION ___ ----
�>
- - ---- -- ---- - - - - -- - - - - -- 311 SCRATCH COAT
309 EXTERIOR LATH
602 ROOF PLYWOOD NAIL
601 ROOF TEAR OFF
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 a(�cuperiino.org
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o (ii t' _ R i,�r I�.Y,ei(�Q,�t.�� I ✓h PH � 6 Z�J l�� E-MAIL
STREET ADDRESS0 ` �v,STATE ^ ` FAX
Ap C qN*I N PHONE C EMAIL
STREET-AaDRESSI An � � S� >STATE.ZIP � 7/ FAX .
❑ OwNER ❑ OwNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
C ffCwr(�R N LI NUMB TE
TYPE BUS.LIC.#rE��A� �CAI
vl
COMP W' A/G GQ E-MAIL FAX
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STAN,P�j 8 cuV Mor
.r'•�V /jC STATE C _ 12
ARCHITECr/ENGWME EER NALICENSE l BUS.LIC.#
COMPANY NAME E-MAM FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF FD or Duplex ❑ Multi-Family ROOF A: VALUATION: I�{ ,� ni rl k�
STRUCTURE: ❑ Commercial � V41
a' (164
EXISTING ROOF TYPE: UILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER(SPECIFY)
REMOVE/REPLACE ❑YES IF NO, PLYWOOD �'h" 11PLYWD El OSB PITCH: ROOF
O #LAYERS T-rI1CKNESS: El 5/8" TYPE: CDX 12 CLASS: A
PROPOSED ROOF TYPE: ❑BUILT-UP ROOF ❑ASPHALT sHINGLEs ❑WOOD SHAKES ❑WOOD SHINGLES 9 0723FR ICC-ES REPORT#
DESCRIPTION OF WORK r
O(�t/�. pev
By my signature below,I certify to each of the follo ' g: I the property owne r au rized agent to act on the property owner's be . I have read this
application and the information I have provided is rrect have read the Desc' tion of •rk and verify it is accurate. I ee to co y with all applicable local
ordinances and state laws relating to building c frac' n. I a rize r pres tatives o Cupertino tc enter the ae jrfitified p err :`or inspection purposes.
Signature of Applicant/Agent Date: V ��
SUPPLEMENTAL ORMATION REQUIRED
_If building is associated with a Home Owner's Association,provide letter ,�- _
of approval from HOA. R r�zm `BUII-DIN
—Provide Planning approval to verify if there any restrictions. • KIT-
S x PZ,�l21NIidGPLA1VREVIEW
P-h
Provide copy of Manufacturer's Installation Specifications.
II-sraNfiA�n z �-,�. ❑�-�Ix�nz�x
c f_mvide signed copy of Cupertino's Tear-Off Policy.
ReroofApp_2011.doc revised 03/02/11
CITY OF CUPERTINO BUILDING PERMIT OATS: _/ ._-2- /
BI'ILDING ADDRESS: 10400 RIDG17VIFW Ch CON'T'RACTOR:DFVCON CONSTRUCTION PERMIT NO: 11050264
INC:
'2'S NAME: APPLE 690 GIBRALTAR DR DATE ISSUED:06/15/2011
ON%NER'S PHONE: 4089745662 MIL,PITAS,CA 95035 PHONE NO:(408)942-8200
❑
LICENSED CONTRACTOR'S DECLARATION j F (�
��j
BUILDING PERMIT INFO: BLDG ELECT PLUMB
n
Licese'Class_-- --- Lic #-3tl F F
{- MECH RESIDENTIAL COMMERCIAL
�K
Contractor l P�� GWr Date
1 hereby affirm That I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: ELECTRICAL HOOK UP AND DISTRIBUTION 1-IVAC UNI'l
(commencing with Section 7000)of Division 3 of the Business& Professions DUCT
Code and that nry license is in full force and effect. WORK FOR ADDED TEST CHAMBERS AND POWER SUPPLIES
I hereby affirm under penalty of perjury one of the following two declarations: 8/01/2011 -REV#1 -2 AIR HANDLEING UNITS-8/18/2011 REV#I ISS'D
I have and vHill maintain a certificate of consent to self-insure for Worker's
Compensation.as provided for by Section 3700 of the Labor Code, for the
perlornnancc of the work Ior which this permit is issued.
I limc and v%ill maintain W'orker's Compensation Insurance,as provided for by
Sccuon 3700 of the Labor Codc,for the performance of the work for which this
permit Is issued. Sq.Ft Floor Area: Valuation:$80000
APPLICANT CERTIFICATION
I cerut\_ that I have read this application and state that the above information is APN Number:31606046.00 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
indemni1v 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 consequence of the
grantufg of this permit Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
\�,th all non-point source regulations per the Cupertino Municipal Code,Section
18 ]80 DAYS FROM LAST CALLED INSPECTION.
y Date Issued,jyyri Date:
❑ O\VNER-BUILDER DECLARATION
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.11'a roof is
L 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
vv ill do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
liusincss& Professions Code)
L as owner of,file property,am exclusively contracting with licensed contractors to Signature of Applicant: Date-
construct the project(Sec-7044,Business& Professions Code). ----
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 sell=insure for Worker's
C'ompensatron,as provided for by Section 3700 of the Labor Code,for the
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued. 1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Scclion 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(a)should I store or handle hazardous material.
pernut 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 1 will
not employ anN person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,atter making this certificate of exemption,I Health&Safe Code,Sections 25505,25533,and 25534.
hcconnc subject to the Worker's Compensation provisions of the Labor Code,I must
Iiorth\cith comply with such provisions or this permit shall he deemed revoked. O r rizedlvttt"
Date•
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I ccrtit' 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 work's
to building construction,and hereby authorize representatives ofthis city to enter for which this permit is issued(Sec.3097,Civ C.)
uP. he above mentioned property for inspection purposes.(We)agree to save Lender's Name
Jv and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the Lender's Address
er:i:;onr,of this permif Additionally,the applicant understands and will comply
1111 all non-point source regulations per the Cupertino Municipal Code,Section
I8 ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature_ — Date
Licensed Professional