12070024 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10570 S FOOTI TILL BLVD CONTRACTOR:CROSS ROOFING CO PERNII'1NO: 12070024
OWNER'S NAME: CIIANDRASEKI IAR&MATIIIAS GORLA 500 EAS'I'ER AVE DATE ISSUED:07/(15/2012
OWNE:R'S POONF.: 4086055191 MILPITAS,CA 95035 11110..NE NO:(41104)262-2574
0 LICENSED CONTRACTOR'S DECLARATION
(J• r Q BUILDING PERMIT INFO: BLDG r ELECT r PLUMB
(�
License Class `-'3-f Lic.N 43-C/ �1—5 , r r r
�. � 1 �nL/� alECll RESRESIDENTIALCoatal E:ItCI.\1.
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Contractor 1 HSN L/r l/J J' Dale
1 hereby affirm that 1 nm licensed under the provisions of Chapter JOB DF.SCRI PTION: RIfMOVI-.(R)SI IAKE ROOT'& INS'IALI.A GAPIELK
'I IMBERLINE-VI'I'RA COMPOSI f ION SI IIN(II,E(CONP)ROOF
(commencing with Section 7000)of Division 3 of the Business&Professions OVER(E)SI IIIA Il IING
Code and that in)'license is in full force and effect.
1 herchv affirm under penally of perjury one of the following two declarations:
I have and will ntaintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
perExntance of the work fix 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 work for which this Sq,Ft Floor Area: Valuation:S9500
perlllil is issued.
AI'I'I,IG\N['CER]'IFICATION .\PN Number:35705017.00 Occupanev'I'ypc:
I certify that I have read this application and state that the above information is
correct I agree it,comply with all city and county ordinances and stale laws relating
10 building construction.and hereby authorize representatives of this city to enter
upon the above mentioned property['or inspection purposes, (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City oi'Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence ofthc WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting ofthis permit Aiditionait -t cap cant understands and will comply Igo PAYS FROM LASTCALLED INSPECTION.
crit l - ownsource reaulali s per the C pertino Municipal Code.Section
9.18.
I li Issued by;:�%�� Date: i 2
Signaturc -Dalt 111
❑ 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 prim to an)'rooting material being installed.Ifo roof is
the fullouing two reasons: installed without first obtaining all inspection.I agree to remove all new materials lin
1,as owner ollhc 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&Profcssions Code) Signature ol'Applicnm: Date:
L 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"012 BF.TI Fit
herchv affirm under penalty of perjury one of the following three
declarations: IIA%ARDOUS,%IA ITRIAI S 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 requiremems under Chapter 6.95 ol'the
California Health&Safeq Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work far which this permit is issued.
ns provided for b compliance with the Cupertino.aluniripal Code.Chapter 9.12 and the Ilealth&
I have and will maintain Worker's Compensation Insurance, p y
p S:deq'Code.Suction 25532(4)should 1 stare or handle hazardous material.
Section 3700 ol'the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. comaminanls as defined hg the IN'% Area Air Quality\l:may,emeul Dist,icl I Bill
I cenily that in the performance of the work for which this permit is issued.I shall maintain compliance with the Cupertino Nlumcipal Code.Ctrainer 9.12 and mite
not employ any person in any manner so as to become subject to the Worker's Ilealth&Safety Code,.'-cht )s 25505,25533,and 25534.
Conlpcnsation laws of California. If,alter making this cc it of exemption,I /1 r—( 9
become subject to the\Porkers Compensation provisions of the Labor Code,I must O� ngenP '(,/J
I(/r Date:
fonhwith comply with such provisions or this permit shall be deemed revoked- (
CON:S'l IOjC-PION LE:.NDING:\GFN(:N'
APPLICANT CERTIFICATION
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 perlilmlance of work'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
indenmify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which nine accrue against said City in consequence of the
granting of this permit.Additionally the applicant understands and will comply ,\RCI I I'I'EC'I'S DF.CLARA HON
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18 1 understand my plans shall be used m public records.
Signature Date Licensed Prut'essional
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10570 s.foothill blvd. DATE: 07/05/2012 REVIEWED BY: bobs.
APN: BP#: 'VALUATION: $9,500
"PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration/ Repair
PRIMARY SFD or Duplex PENTAMATION 1 SFDWLROOF
USE: PERMIT TYPE:
WORK re-roof tear off existing shake replace with conp shingles.
SCOPE
Nrcb. Plan ('her'/r Phunh. P/ma Owc-Ak-le, PLm Cask
I.llrrb. Permil Fee: Plumb. Permit F,•c: Isle. Pe""ir Fw-
Other e,/7h In.ap. Other Plumb Imp, Li I Utber 1:10. Insp.
H..'h. Gap. Fee: Plumb. Gasp. Fee: /i/tt'. brrp.
NOTE: This estimate does not includejees due to other Departments(Le. Planning, Public Works, Fire,Sanitary Sewer District,School
District,etc). Thesefees are based on the prelindna information available and are only an estimate. Contact the De 1 or addn7 info.
FEE ITEMS (Fcc ltesalation 11-053 LIT 7/1/111 FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 3,500 s.f. Re-roof
Suppl. PC Fee: Q Reg. 0 OT TO.0 hrs $0.00 $525.00 IREROOFRES
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. lnsp. Fee:Q Reg. 0 OT 0,0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Culrslntrnon fax.
Jelin usnariveFer: 0
Work Without Permit? 0 Yes 0 No $0.00 0
Advanced Planning Pee: $0.00 Select a Non-Residential G
TravelUocun7rnlnrinn Fees: Building or Structure 0
i
Slront Motion Fcc: IBSEISMICR $0.95 Select an Administrative Item
Bide,Sids Commission Fee: IBCBSC $1.00
"'•t SUBTOTALS: $1.95 $525.00 — TOTAL O]E:
7, $526.95
Revised: 07/01/2012
REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333•building(Wcuoertino ora 120
PROJF:CTADDRESS /T�r�O S/ OD'r/lI II VWI APN9 '3�5%
OWNTR NAAm Chl�l•((',�f�J Q / G6 _ 'PHONE E.\IAIL
STREET ADDRESS CrIY, STATE,ZIP
FA\
CONTACT NAMEO I.\4�
K PHONE
STREET ADDRESS CRY,STATE, ZIP
FAX
13 OWNER ❑ OWATR.OUILDER ❑ OWNIiRAGENr 0 CONTRACTOR ❑coN, CTOR AGENT ® ARCHITECT ®LFGL\TER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAAff 1/I Q A/1 LICENSE NIJMB
�I- /°/ 3GG6 nn9^^l,^5 I.ICk/NS[i TYPE,."ClIiUS,LIC,
COA�ANY NAME cross �{ ovfi Lib EMM./J AOSJ/�f��CONC4-eff ({- J FA.\ ✓ v
5TRFI:T ADDRESS �`jr, �.rr��rA n CITY.STATE,ZIPu/ / f � �� (/S Lam' PITO\} ahaa5��
iVtCH -. 'F72 NAME L/� �lJ C+L LICENSE NU\�ER I`
COMPANY NAAIF.
FAX
STREET ADDRESS CITY,STATE.ZIP
PHO\T
usE OF t S;orDupl" ❑ Multi-Family ROOFAREA: VALUATIONSTRUCRJRE; ❑ C
LASTING ROOF TYPE,.: ❑RUR.T-LPROOF ❑ASPHALT SHINGLES bVOOD SHAKES ❑woODSHLNGLES ❑OTHER(SPECIFY)
RF_\fOVEAOPLACE PITS I IF NO. PLYWOOD %- ❑ PLYWD ❑oSR PRCII: 1J
❑ u nucKNrss ❑ �-+ :12 ROOF
I ^ 13tt1
PROPOSED ROOF TYPE: ❑HUR,T-UPROOF )(ASPHALT SHINGLES 13 WOOD SHARES ❑WOOD SHINOLFS ❑OTIRR ICC-ES REPORT
DESCRIPTION OF WORK: "L
`I n I II I��
AF �l ry►,���Fuc— f(q 05 1 tj71 6AI N te- 1 O-O fo tl..e-U
KI �u "LAAiu
By my sign tune below,1 certify to each of the following: I am the property owner or authorized agent to act on DtcProperty
application and the informati ve provided is correct. 1 h read the Description of Work and verify it is acthe r. gree Tl co plhalf I have readis local
ordinances and stale laws rdRting to b 'ding consuucuon. eultr riu rcprese Wes of Cupertino to enter the ccuraall
Pert 1 lifted property fo inspection purposes.
Signature of ApplicanOAgen1: Dale G_I
SUPPLEMENTAL INFORMATION REQUIRED !!! OFFICE USE ONLY
If building is associated with a Home Owner's Association,provide letter PLAN CRECK TVPE ROWING SUP
of approval from HOA. f]^OVER-TFg couNTER ❑- tnLDING P1A1'REVIEW
Provide Planning approval to verify if there any restrictions.
❑ ErtPRESS ❑ PLANNING PLAN REVIEW
Provide COPY of Manufacturer's Installation Spec cations.
❑ STANDARD ❑ FIRE,.DEPT
✓Provide signed copy of Cupertino's Tear-Off Policy. ❑ OTHER
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