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11030066 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21675 REGNART RD CONTRACTOR:WORRELL ROOFING CO. PERMIT NO: 11030066 OWNER'S NAME: KENNETH HIGASHIHARA 3790 EL CAMINO REAL DATE ISSUED:03/14/2011 0"INER'S PHONE: 6502488224 PALO ALTO,CA 94306-3314 PHONE NO:(650)222-0493 L L�I�CENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG f— ELECT I— PLUMB r License Class (.." 3 Lie.# l� L� L O 01 MECH RESIDENTIAL COMMERCIAL Contractor _ �s"7�c..��G/ Date 7' �— � � I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:ROOF REPAIRS TO EXISTING OVERHANG MATCHING (commencing with Section 7000)of Division 3 of the Business&Professions EXISTING CLASS A FIBERGLASS SHINGLES(3SQFT) 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,as provided for by Section 3700 of the Labor Code,for the performance of the workf� wh this Sq.Ft Floor Area: Valuation:$5000 permit is issued. APPLICANT CERTIFICATION APN Number:35624038.00 Occupancy Type: I certify that I have read this application and state that the abo a 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the 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 180 DAYS FROM LAST CALLED INSPECTION. with all non-point so cc re ons per the Cupertino Municipal Code,Section 9.18. 3 Issued by: Date: Signature Date_ OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for 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 1,as owner of the property,or my employees with wages as their sole compensation, inspection. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signature of Applicant: Date: 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain 1 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. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the 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 become subject to the Worker's Compensation provisions of the Labor Code,I must Ow ed a /� forthwith comply with such provisions or this permit shall be deemed revoked. Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of Hork's correct.I agree to comply with all city and county ordinances and state 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 indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address c--'- and expenses which may accrue against said City in consequence of the ig of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO 4 ITEMS OF 5 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 35624038. 00 DATE ISSUED. . . . . . . : 03/14/2011 RECEIPT #. . . . . . . . . : BS000012894 REFERENCE ID # . . . : 11030066 SITE ADDRESS . . . . . : 21675 REGNART RD SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : KENNETH HIGASHIHARA ADDRESS . . . . . . . . . . : 21675 REGNART RD CITY/STATE/ZIP . . . : CUPERTINO, CA 95014 RECEIVED FROM . . . . : FRED WORRELL CONTRACTOR . . . . . . . : FRED WORRELL LIC # 27857 COMPANY . . . . . . . . . . : WORRELL ROOFING CO. ADDRESS . . . . . . . . . . : 3790 EL CAMINO REAL CITY/STATE/ZIP . . . : PALO ALTO, CA 94306-3314 TELEPHONE . . . . . . . . : (650) 222-0493 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 5, 000. 00 1. 00 0 . 00 1 .00 0. 00 1BSEISMICR VALUATION 5, 000. 00 0. 50 0 . 00 0 .50 0. 00 1INSPMIS HOURS 1. 00 126.00 0 . 00 126 .00 0 . 00 1REROOFRES SQ FEET 3 . 00 39.00 0 . 00 39.00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 166.50 0 . 00 166 .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 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 MISIC GUPERTINQ (c) o. (408)777-3228• FAX(408)777-3333•buildinpcupertinorq P f2A p*° /L 5 ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL 9IISCELLANEOUS PROJECT ADDRESS ' 7 e jv 4 2 APN 1_ 1775 L4 OWNER NAME " �c�• l 1 ►�/� G� PIlosp kIZ E-MAIL r` 1 STREET ADDRESS n '/ 7 Re jy A r ,- CITY, STATE,ZIP^v e` �U FAX APPLICANT NAME G (p r PHONE ` E-MAIL (,Jo 2�2 e l( 2 0 t C-0 --7 Z 2 —D N a1 STREET ADDRESSJ,7 41 d £/ 04y", 1410 Pl(620 CITY,STATE,ZIP FAX r g ,p,t�1-o C� �� v8 5Y�3s8F3 ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ;<ONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE N BERLICENS�PE BUS.LIC# o floe 119 .7 17 COMPANY NAME E-MAIL A? 2 IL 4>0 2� << ��/V C�& - FAX #-V- �j STREET ADD 3 9'0 / 46*1-0 _ /� Q CTI Y. TATE,ZIP I - ^ ��/ PHONE ARCHITECT/ENGINEER NAME f J� LICENSE NUMBER y BUS.LIC# 7 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF PROJECT IN WILDLAND PROJECT IN STRUCTURE: esidential ❑ Commercial URBAN INTERFACE AREA ❑ Yes ja NO FLOOD ZONE ❑ Yes �El NO DEscRUMOrt of woRxj2i' E `.► --- . c$ t TOTAL VALUATION: S �' RECEIYEDBY, 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 din Jnistryction. I author a representatives of Cupertino to enter the above-identified property for inspection purposes. Signature of Applicant/Agent: � Date: SUPPLEMENTAL INFORMATION REQUIRED 0MCE usE ONLY THE-COUNTER. ❑- EXPRESS STANDARD LARGE Rta �XASOR MEPMiscApp_2011.doc revised 03/02/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 21675 regnart dr DATE: 03/14/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$5,000 Y-,PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof PRIMARY SFD or Du lex PENTAMATION 1 SFDWLROOF USE: P PERMIT TYPE: WORK re air roof overhang matching existing class A fiberglass shingles SCOPE FEE ID ROOF AREA s.f. 1REROOFFRES 300 T7 I T Li NOTE. Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addn7 info, FEE ITEMS (Pee Resolution 09-051 I ff. T1,"I0) FEE QTY/FEE MISC ITEMS Permit Fee: $39.00 Work Without Permit? 0 Yes No $0.00 Str�Motion Fee: 1BSEISMICR $0.50 1.0 hrs Inspections Bldg Stds Commission Fee: 1BCBSC $1.00 $126.00 IINSPAKS Standard Inspections SUBTOTALS; $40.50 $126.00 TOTAL FEE: $166.50 Revised: 01/15/2011 WORRELL ROOFING SINCE 1977 City of Cupertino LIC# 348820 Community Development Dept. - Building Inspection 10300 Torre Avenue Cupertino CA 95014-3255 (408) 777-3228 Subject: Building Permit & Drawings Site: Kenneth Higashiara Residence 21675 Regnart Cupertino, CA 95014 Attached is a drawing of work done with supplemental photos and copy of "Scope of Work". What started out as a simple eve repair ended in having to replace the sheathing and change out fiberboard to 1/2" cdx. on top of decking to keep the roof level. .n . 4. s y n..;jri F 3 cw s . . 3790 EI Camino Real PMB 208 Palo Alto, CA 94306 Tel: (650) 494-8166 Cell: (650) 222-0493 Fax: (408) 997-3588 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: 2 l RC-S IMF PERMIT# 4::� OWNER'S NAME: Wv PHONE# ji�S-b- GENERAL CONTRACTOR: \t l a 2 BUSINESS LICENSE# ADDRESS:_Zy-?-9,*� 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 SIAM A^TRACTORS 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: 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 Owner/Contractor Signature Date