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11050019 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20265 NORTHGLEN SQ CONTRACTOR:FOUR SEASONS ROOFING PERMIT NO: 11050019 OWNER'S NAME: HENRY MA PO BOX 1668 DATE ISSUED:05/03/2011 OWNER'S PHONE: 4082780330 SAN JOSE,CA 95109 PHONE NO:(408)278-0330 G LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT f— PLUMB License Class Lic.# % 7 MECH r— RESIDENTIAL F- COMMERCIAL f— Contractor Date I hereby affir at�Ia"Ii nsed under the provisions of Chapter 9 JOB DESCRIPTION:RE-ROOF REMOVE EXISTING CEMWOOD ROOF& (commenci with SOil)of Division 3 of the Business&Professions INSTALL NEW 309 UNDERLAYMENT&GAF GRAND CANYON ASPHALT Code and that my license is in full force and effect. SHINGLES COLOWSTONEWOOD,HAS EXISTING PLYWOOD 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. 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 permit is issued. Sq.Ft Floor Area: Valuation:$4400 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:31639010.00 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 indemnify 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 granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. Signature — Date �(� Issued hic!' Date:- L CILDER 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 I,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) - I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three Al-ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE 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 read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I 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 employ any 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,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533,and 25534. become subject to the Worker's Compensation provisions of the Labor Code,I must Owner o if orize forthwith comply with such provisions or this permit shall be deemed revoked. Date: APPLICANT CERTIFICATION -.--Cg}y TRUCTION LENDING AGENCY 1 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 here affirm that there is a construction lending agency for the performance of work'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, co-` and expenses which may accrue against said City in consequence of the Lender's Address gi ,of this permit.Additionally,the applicant understands and will comply wi:_,ail non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional REROOF PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408)777-3228 • FAX(408)777-3333 • buildingQcupertino.orq CUPERTINO PROJECT ADDRESS ^O� APN� OWNER NAME O[ PHONE E-MAIL Q�l� /til r4 vGff ��8'-o,33a STREET ADDRESS / — CITY, STATE,ZIP FAX APPLICANT NAMEp P IO E-MAIl, c vRzur �0S -3 STREET.ADDRESS CITY,STATE, FA SD Z �-Irc.�r.,.-,� 7• �-,n. -��.e. �•�s'e/ � Z?d'-X33 ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS LIC # 2rn Ce.2 cre c Ll o COMPANY NAME (5t_)( Se _ _ 1'-C- 1 E-MAIL FA>�r�_5�`� STREET.ADDRESS 5 &-`1 CIT ,STATE ZIP PHONES Sb� rCSrrurt T. G� cl // Z L oS�.2-78-0_U0 ARCHITECTrENGI NEER NAME 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 (�/ _ �O /Jn EXISTING ROOF TYPE C3BUILT-UPROOF 13 ASPHALT SHINGLES C3 WOOD SHAKES 1:1 WOOD SHINGLES ti`11 ER(SPECIFY)/ ' m�Do� RENIOVE,REPLACE >i::2ES IF NO, PLYWOOD 11 '/" ❑ PLYWD ❑ OSB PITCH: l C� ROOF ❑ NO #LAYER : THICKNESS: 115/8" PE: ❑ DX 12 CLASS f1 PROPOSED ROOF TYPE: ❑BUILT-UT ROOF A<$PHALT SHINGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT# DESCRIPTION OF WORK. ` n }.�{�t,.� C7 v �Q.� � ,rV.,e-.�C-' � �V4-� tom( �}�v j� �� ►'LQl.-1--` ►,,: l�Sif olor: 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 b Iding nstruc ion. I authorize representatives of Cupertino to enter the above-I entifJied property for inspection purposes. Signature of ApplicanUAgent: Date: � � k, (s '11d 8': a. n� •:; fig a swy.",, a r3 SUPPLEMENTAL INFORMATION REQUIRED ��.; , ,.. oi+ cEQSEaNL If building is associated with a Home Owner's Association,provide letter PLetiNSECK IYpE TINGsLIP of approval from HOA. VER-THE.CQUNTER".. BUILDING PLAN REVIEW r, - Provide Planning approval to verify if there any restrictions. ❑ 'EXPRESS ❑` PLANNING PLAN REVIEW Provide copy of Manufacturer's Installation Specifications. 0,sxnrrDAiin ❑ `RIREnEPT Provide signed copy of Cupertino's Tear-Off Policy. ❑ OTHER: ReroofApp_2011.doc revised 031021 11 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 20265 northglen square DATE: 05/02/2011 REVIEWED BY: bobs. APN: BP#: 'VALUATION: 1$4,400 *PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof PRIMARY SFD or Duplex PENTAMATION 1 SFDWLROOF USE: I I PERMIT TYPE: WORK remove existing cemwood roofing, replace with comp shingles. SCOPE FEE ID ROOF AREA s.f. 1 REROOFFRES 1,400 Lj NOTE: Thesefees are based on the preliminary information available and are only an estimate. Contact the De t or addn'l info, FEE ITEMS (Fee Resolution 09-051 Eff 7/1.%"10) FEE QTY/FEE MISC ITEMS Permit Fee: $182.00 Work Without Permit? 0 Yes G No $0.00 Strong Motion l=ee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $183.50 :$0:0±0 TOTAL FEE: $183.50 Revised: 04/29/2011 CITY OF CUPERTINO 3 ITEMS OF 18 PERMIT RECEIPT OPERATOR: TraciC COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 31639010 . 00 DATE ISSUED. . . . . . . : 05/03/2011 RECEIPT #. . . . . . . . . : BS000013366 REFERENCE ID # . . . : 11050019 SITE ADDRESS . . . . . : 20265 NORTHGLEN SQ SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER HENRY MA ADDRESS . . . . . . . . . . : 20265 NORTHGLEN SQ CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-5046 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 4,400 . 00 1. 00 0 . 00 1 . 00 0 . 00 1BSEISMICR VALUATION 4,400 . 00 0 .50 0 . 00 0 .50 0 .00 1REROOFRES SQ FEET 14 . 00 182 .00 0 . 00 182 . 00 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 183 .50 0 . 00 183 .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