12100083 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10596 WHITE FIR CT CONI'RACPOR:FOUR SEASONS ROOPING PERMIT NO: 12100083
OWNER'S NAME: LO LAWRENCE LONG-FA AND LIN JOAN CH 1'0 BON 1668 DATE ISSUED: 10/112012
OWNER'S PRONE: 4089968422 SAN JOSE.CA 95109 PHONE NO:(108)278-0330
❑ LICENSED CONFRACFOR'S DECLARATION BUILDING PERMIT INFO: BLDG 1- ELECT❑ PLUMB
Fj
License Classf.1-1 Lia H
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A1FCH (- RESIDENTIAL Cl COMMERCIAL (_I
Contractor &Date 10//-),Av
hereby affirm that I am licensed under-Me e provisions of Chapter 9 JOB DESCRIPTION:TEAR OFF EXISTING WOOD SHAKE ROORINSTALL NEW
(commencing with Section 7000)of Di%ision 3 of the Bu51aei5 S Professions I2"
Code and that my license is in full force and effect. CDN PLYWOOD AND 30M FELT UNDERLAYD1ENT.INSTALL 13
SQ NEW CERTAINTEED PRESIDENTIAL-COMPOSITION
hereby nffrm 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 3700bf the Labor Code,for the performance of due work for which this
permit is issued. Sq.Ft Floor Area: Valuation:54500
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above infomtation is APIN Number:35905130.00 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 hammlessthe City ofCupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may aceme 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 n"int int source regulations per the Cupertino Municipal Code,Section 180 DAYS LAST CALLED INSPECTION.
9.18.
Signal
Date
—ld Issued' y: A Date:
❑ OWNER-BUILDER DECLARATION K/
1 hereby affirm than am exempt from the Contractor's License I-a" for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material beitg installed If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, installed without firsVing an inspection,I agree to remove all new mat rials for
will do the work,and the structure is not intended or offered for sale(Sea.7044, inspection. agree
to
Business B Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applic
construct the project(Sce.7044,Business g Professions Code).
hereby affirm under penalty of perjury one of the following three ALL ROOT'COVERINGS TO 13E CLASS"A"OR BE'ITF-R
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
I have and will maintain Worker's Compensation Insurance,as provided for by California lleallh S Safety Cudc.Sfetions 25505,25533,and 25534. 1 will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.L and the I lealth S
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 forwhich this permit is issued,I shall contaminants as defined by the Ray Area Air Quality Management District I will
not employ tiny person in any manner so as to become subject to the Worker's main compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation law's of California. If,after making this certificate of exemption,I 11 d t Safety Codf Sectio 255 5,255 ,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. O. err o horiz, age / // 5_
APPLICANT CERTIFICATION CONSfRIIC`FION LENDING AGENCY
I certify that I have read this application and state that the above information is
correct.I agree to comply with all citand county ordinances and state laws relating I hereby affirm thin 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.('Ale)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Cade,Section ARCH ITTCI"S DECLARATION
9.18.
1 undersand my plmu shall be used as public records. /
Signature Date
Licensed Professional
r
CUPERTINO I
�. � • v •VVV
(408)777-3228• FAX(408)777-3333•buildingCcDcupertino.org
( 2-( o c7U
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REROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTI NO,CA 95014-3255
CUPERTINO (408)777-3228- FAX(408)777-3333•buildingl55cupertino.org
PROJECT ADORE j,� (Q ^ 6 ktfi[�irn jr:l p �aPN.
OWNE ME PHONE 6 E-MAIL
AIL
! C ( CII' 1TATE.LIPitlt� M PAX
CONTACT NANIF f0 PHOVE J`+E-MAIL
tt4ak-708-63*301
STREEr ADDRESS Sot ^ S I CITY.STATF ZIP FAX
❑
OWNER ❑ OWNER-RUILDER ❑ Ow'NF.RAGENT Je CONTRACTOR ❑CO�RACTORAGERT ❑ ARCHDECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME LICENSE NUMBERLICENSE PE BLS.LIC..ye�gar�" 2 O -
COMPANY NAME E-"SAIL FAX
SAME
wq
STREET ADDRESS CITY.SLATE ZIP
Sot I a ose CA.9S112,
PHONE"AOS-Zat-OAR
ARCHrrECTrENGINEER SAME LICENSE NGMSER BUS.LIC.e
t
COMPANY NAME r ,I E-MAIL FAN
t
STREET ADDRESS CITY,STATF_ZIP PHONE
TI
USE OF ❑ SFD or Duplex JIJ Multi-Family ROOF AREA: VALUATION:
STRUCTURE: ❑ Commercial .S 5 -
EXISTINGROOFTYPE: ❑RUILT-CPROOF ❑ASPI[ALT SHINGLES ��PeWOODSHAKES ❑WOODSHINGLFS ❑01'1 IFR(SPECIFY)
REMOVF!REPLACE IS IF NO. PLYWOOD J7il'i ❑ PLYw'D ❑OSB PITCH. ROOF
❑ '7FOS
LAYER THICKN ❑ La' TYPE. -DX '1 L CLAS A
PROPOSED ROOF TYPE: ❑BUILT-UPROOF X(ASPHALTSHINGLES ❑WOODSHAKES ❑ROOD SHINGLES ❑OTHER ICC-FS REPORTS
DESCRIPTION OF WORK: _,.11
F13wo4d+6en 3o# At undelrl"M� If-,II [&Ck li{.s
Cerkw; se PreSjded+�wj COMO Color : CauAcy Graq .
By my signature below.I cenin'to each of the following: I am the property owner or mahonzed agent to act on the proper'owner's behalf. I have read this
application and the information I have provided is correct. 1 have lead the Description of\v'ork and verify it is accurate. I agree to comply Ivith all applicable local
ordinances and state laws relating to building cons tion. I a Drize represe [iv of Cupertino to enter Ne above-identilled property for inspection purposes.
Signature of ApplicanUAgcn[: Dam: /424312--
SUPPLEMENTAL
O
SUPPLEMENTAL INFORMATION REQUIRED OFFICEUSEONLY
_I f building is associated with a Home Owner's Association.provide letter PWN CHECK TYPE ROu T[NC SLIP
of approval from HOA. LOVER-THE-COUXTER BUILDING PLAN REVIEW'
Provide Planning approval to verify if there any restrictions. 6 Fa PRF55 ❑ PW NNINC PWN REVIEW
Provide copy of Manufacturers Installation Specifications. ❑ slwNnARn ❑ FIRF.DEPr
Provide signed copy of Cupertino's Tear-Off Policy. ❑ OTHER:
( XeroofiApp_201 Ldoe revised 03/16/11