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11010012 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10225 LEBANON DR CONTRACTOR:BUCK'S ROOFING PERMIT NO: 11010012 OWNER'S NAME: SISSON HELEN P 6853 W RIVERSIDE WAY DATE ISSUED:01/03/2011 ("'INER'S PHONE: 4082572136 SAN JOSE,CA 95129 PHONE NO:(408)605-1681 Ll LICENSED CONTRACTOR'S DECLARATION I r- r _ BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.it 13 9 S q 3 F F MECH RESIDENTIAL COMMERCIAL Contractor 3yck-S ki I +'7`' Date /-3— // I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:RE-ROOF REMOVE CAP SHEET ROOFING,INSTALL (commencing with Section 7000)of Division 3 of the Business&Professions 72#CAP Code and that my license is in full force and effect. CLASS A 18SQ 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 work for which this permit is issued. � Sq.Ft Floor Area: Valuation:$8000 APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above informs is APN Number:34214017.00 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. r Signatur Date 3 �� Issued by: Date: / 6 OWNER-BUILDER 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 SWature of Applican• �_�— Date: construct the project(Sec.7044,Business&Professions Code). I 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 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 Health&Safety Code,Sections 25505,25533,and 25534. I will maintain 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 forthwith comply with such provisions or this permit shall be deemed revoked. O er o authorized agent: / 3 "�-- Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 I hereby 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, and expenses which may accrue against said City in consequence of the Lender's Address ing of this permit.Additionally,the applicant understands and will comply wan all 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 CITY OF CUPERTINO 3 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN 34214017 . 00 DATE ISSUED. . . . . . . : 01/03/2011 RECEIPT #. . . . . . . . . BS000012371 REFERENCE ID # . . . : 11010012 SITE ADDRESS . . . . . : 10225 LEBANON DR SUBDIVISION . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . OWNER SISSON HELEN P ADDRESS 10225 LEBANON DR CITY/STATE/ZIP . . . : CUPERTINO, CA 95014-2679 RECEIVED FROM . . . . : BUCK'S ROOFING CONTRACTOR . . . . . . . : LARSH, JIM LIC # 21470 COMPANY BUCK'S ROOFING ADDRESS 6853 W RIVERSIDE WAY CITY/STATE/ZIP . . . : SAN JOSE, CA 95129 TELEPHONE . . . . . . . . : (408) 605-1681 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BCBSC VALUATION 8, 000 . 00 1 . 00 0 .00 1. 00 0 .00 1BSEISMICR VALUATION 8, 000 . 00 0 . 80 0 . 00 0. 80 0 .00 1REROOFRES SQ FEET 18 . 00 234 .00 0.00 234 . 00 0 .00 ---------- ---------- ---------- ---------- TOTAL PERMIT 235.80 0 . 00 235. 80 0 . 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 350 .80 #1826 --------------- TOTAL RECEIPT 350 .80 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 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 10225 lebanon dr. DATE: 01/03/2011 REVIEWED BY: bobs. APN: BP#: *VALUATION: 1$8,000 PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof PRIMARY SFD or Du lex PENTAMATION 1SFDWLR00F USE: P FI,(10 t h i:�J PERMIT TYPE: WORK re-roof. SCOPE FEE ID ROOF AREA s.f. 1 REROOFFRES 1,800 cch. (Tarr('ht:ck Plomb. I'Inn(ht)(A P/�M(AcO, Ll>(;ii. A riIIi/l`ce' 1'7?;r?zb I'r ini V,°f: t-.7c.r 1'e1-t0 rit t cc O hu),alucK?asl). C)th",r P r ?tlt J'rr�7> 0 Cltite I7<°c.Irani, 11",h, Inst, F'e' Tiirnh. Ir 7;. F < I`ier. Ii? . I'ae' NOTE. These fees are based on the preliminary in ormation available and are only an estimate. Contact the Dept-for addn 7 info. FEE ITEMS (Fee Resohition 09-05I Eff.7,111.0] FEE QTY/FEE MISC ITEMS Plan Check-P'ec Snppl. P(:`tTec f'lztrrztr.;`,�lcc:lz.il:lec p/all (71W:k: Permit Fee: $234.00 Snppl. Insp I-'Ce f'lnzrzh.; 1IccTz.;I7lc'c: ('nit t�'ec: f'lzrnzfa./�llech. 'I:"lc'c l ciwin 1`cc: (7onstrialIion lax ,2couslic,ol Rcl hns,I'c Work Without Permit? 0 Yes (F) No $0.00 I'lcrnzaizrtr f�'c�<',ti': TI--vel 1)ocuzric.,nlutio;i Fees_ Strong Motion Fee: IBSEISMICR $0.80 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $235.80 $0.00 TOTAL FEE:" $235.80 Revised: 12/07/2010 �5� ,<R0 - CITY OF S II V L> l CITY OF CUPERTINO is REROOF CUPERTINO PERMIT APPLICATION APN# q.:2 14 ( Date: If residential, is house an Eichler? Yes ❑ No If yes, needs planning approval. Building Address: /OZ Z S- Z e,6a.h o-,-i dr, Owner's Name: lIGlzl" l 0 Phone #: HOA: Yes ❑ No If es, provide letter from HOA Z ,j 7 — z/36 Contractor: Phone #: 3/ 3-7 9'?- ILle-k f Ru - j Fax#: Cupertino Business Licensea � Contractor� se #:-7t� �a Type of Roof Covering: Existing: Proposed: XBuilt-Up Roof X Built-Up roof __ Asphalt Shingles ❑ Asphalt Shingles ❑ Wood Shakes ❑ Wood Shakes ❑ Wood Shingles ❑ Wood Shingles ❑ Other(Specify) ❑ Other (Specify) Number of existing coverings ❑ Provide I.C.C.E.S. Report# To be Removed(fCL3Provide Mfgr. Installation Specs. Job Description: 2VWdvf- Coy .Skm,� l-1) 04 h J ,JHJ­A%"I Z, 14 SS Residential I? Commercial ❑ Green Building: Please complete relevant portion of the Confirmed with Planning Dept. if Green Building Checklist & attach it to the application or if there are any restrictions: ❑ applicable, include in plan set & the sheet index. Valuation: I Have Read, Understand and Will Comply with Cupertino's Tear-Off Policy: