10100129 (2) CITY OF CUPER'CINO BUILDING PERMIT
BUILDING ADDRESS: 10822 S BLANEY AVE CONTRACTOR:TRI-CITY ROOFING PERMIT NO: 10100129
OWNER'S NAME: GEORGE PAPADAKIS 4450 ENTERPRISE ST,#106 DATE ISSUED: 10/18/2010
NNER'S PHONE: 4084465296 FREMONT,CA 94538 PHONE NO:(510)797-3901
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT r PLUMB r
License Class Lic.#
MECH f— RESIDENTIAL r COMMERCIAL
Contractor Date JOB DESCRIPTION:REMOVE EXISTING ROOF AND REPLACE WITH CLASS A
MATERIALS,23 SQUARES
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Profession:. '
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarati ins:
I have and will maintain a certificate of consent to self-insure for Worker's
WnOv—
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for whichthis permit is issued. Sq.Ft Floorea: Valuation:$8100
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 APN Number:36923050.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to eni er
upon the above mentioned property for inspection purposes. (We)agree to sav-. 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgmen s,
costs,and expenses which may accrue against said City in consequence of the Issued by: Date:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Sectic a
9.18.
RE-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for c ne of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contracto-s to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for b;
the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code;for the performance of the work for which th s Owner or authorized agent: Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY
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 I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revokes. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information i;
correct.I agree to comply with all city and county ordinances and state laws rn:lating
to building construction,and hereby authorize representatives of this city to ei iter
-on the above mentioned property for inspection purposes.(We)agree to sa-e ARCHITECT'S DECLARATION
emnify and keep harmless the City of Cupertino against liabilities,judgme its,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will coml ly
with all non-point source regulations per the Cupertino Municipal Code,Sect on Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: bethe
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN ;,6923050 . 00
DATE ISSUED. . . . . . . : :.0/18/2010
RECEIPT #. . . . . . . . . 99000000345
REFERENCE ID # . • • • :-0100129
SITE ADDRESS :.0822 S BLANEY AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : GEORGE PAPADAKIS
ADDRESS . . . . . . . . . . : :.0822 S BLANEY AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : GREG GLAESER
CONTRACTOR . . . . . . . : GREG GLAESER LIC # 22198
COMPANY . . . . . . . . . . : 'CRI-CITY ROOFING
ADDRESS . . . . . . . . . . : 4450 ENTERPRISE ST, #106.
CITY/STATE/ZIP :?REMONT, CA 94538
TELEPHONE . . . . . . . . : (510) 797-3901
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------
OLBCBSC VALUATION 8, 100 . 00 1 . 00 0 . 00 1 . 00 0 .00
OLREROOF SQUARES 23 .00 299 . 00 0 . 00 299 . 00 0 . 00
OLSEISM VALUATION 8, 100 . 00 0 . 82 0 . 00 0 . 82 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 300 .82 0 . 00 300 . 82 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ------------------
CREDIT CARD 300 . 82 visa
---------------
TOTAL RECEIPT 300 . 82
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