06120110C
z
CITY OF CUPERTINO
�?'•.a -- ' t
-CONTRAC`�TQR�INF,ORMATIQN ,
BUILDING DIVISION PERMIT
BUILDING ADDRESS :
PERMIT NO.
OWNER'S NAME:
jjkELLICTT KATHLEEN A
235 ST FRANCIS ST
2
NE:
SANITARY NO. CONTROL NO.
(650)369-9063
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I bamby affirm Nat I am mo Imd under provisions of Chapter 9 (commencing
P
with Section?") of Division 3 of NC Business and Profession Code. and my liana u
REROOF EXISTING 16 SQUARES
in full forte and.(ACCL
License Class Liz. Is
Dob Conuazbr
ARCHrrECTS DECLARATION
I understand my plans shall W used as public records
Unrelated Professional
OWNER -BUILDER DECLARATION
1 hereby alTrm Nat I am uempt from the Convector's License Law for the
following baron. (Section ]031.3. Business and Prop d.no Cade: Any city to county
which .,at. a Permit to CO.[. alter, improve, dcauslub. or repair say awcture
! prior to is issuance. also acquires the applicant for such Permit to file a signed summem
is licensed On Of use COn=wfs LiC.na flw(OmPlOr 9
Sq. Ft. Floor Area
Valuation
" W Pursuant to pmvishaw
(commencing with Section 7W) of Division 3ofthe 8usinessand ProkssionsCose)tar
$12000
I Nat he is esempt therefrom and the basis for the alleged exemption. Any violation of
3 2 6 4 5 0 2 8
Occupancy Type
Section 7031.5 by any applicant for a permit wbjecu the applicant to a Civil penalty ofNumber
trot mole than five hundred dollars (55M).
.' Cf V'
0 1. as aw. of the Importy, of my employees with wages v Nei role Compensation,
Required Inspections
will W the work land the sasumure is not intended or offered for sale (Sec. ]044, Business
and Professions Cade: The Conmcbr's Licence law does not apply to an owner of
property who Wilds or im proves thereon, and who does such work himself or through his
own employee, provided On, such impmwemenu are trot imeMed oroffesed Amanda. If.
however. the building or improvement is sold within ane year o(compledon, the owner -
builder will have the buaden of proving Nat he did ret Wild or improve for punpme of
' Qt. as Ower of am aClusiV COnlrsi sling CIN ed mnnhda's b
ct Set.7property,
construct the project (Sec. ]Odd. and Professions Code:) The ConlaxtMs Li
and ;) Th
owner of property who builds or imPmves and
cense Law coca not apply owner of
e m
who contacts for such projecu with a canvacbr(q licenced pursuant b the Convanrrt
Comm,
Licata.
1 am pt under Se C f n
CACO P
I-]uem
Owner , �*�DBau&
NDCL0N/pr
1 hemby affirm under penalty of perjury one of the following declarations:
anwidde
ofComembcede.for
Loon, action
3ab
wlion, aerofor
a nperfokeanceofn-
thi for by Section 3]00 of the labor Code. for Ne performers.. of Cite
woh for which this p<rmit is issued.
h
❑ 1 have and will maintain Worker's Compensation Insurance, as mquima by Steven
3700 of the labor Code, for the performanee of the work for which Out permit is issued.
My WmkeYa Coa,modipn lecou a carrier soul Policy number am:
Carrier. Policy No.:
_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
.
This aemlen need ret be completed ifdb pt,rmit is parent, hundred dollars (SIM)
our less)
I CCOifY Nat in the Performance of the work for which this permit is issued. I shall not
employ any Perron In any mase ab pmC wbjenm Na Worker3COmpPnydom
Laws of California. QjN - J ca c
Applicant C)
NOTICE TO APPLICANT: if, after making Nu Ccnifcab of Eacmptioo, you should
become subject to the War c's Compensation provisions of the Ia cr Coat you muss
frMwlLh comply with such pmv6imas or this permit.hall he deemed mwkCd,
i CONSTRUCTION LEN. INOAGENCY
I M1or that 4,nON
u a co lensing agtnry for Ne Peaformanw of
which
the work for which Nu permit u tuucd (Sec. 309], Civ. C.)
of h Sot,.
jlender's Nam.
I<ndeYS Adams
'
j 1 mot Nat 1 have lead this application and sub that On oboe information u
' comet. I agree to comply with all city and county ordinances and state laws relating to
building Construction, and hereby a"Noriae rCPrcacnmdves Of his City to enter upon the
1 saws -mc Props ran a pection s.
(Wt,) agnce to save, im crani fy and keep harmless the City Of Cupertino against
judgments, granting
j costs which may in anyway seeme against wig City
incoities,judgmenhe of thisumit.
SNisDWiL.
of UNDERSTANDS
A APPLICANT
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON -P INT
Issued by: Date
SOURC EG NS. e zo 06
Re -roofs
S, uncof ApplicanVComai Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will Ne applicant or future building occupanssbre or handle ha earaoa material
0 defnncd by the Cupertino Municipal Code. Chapter 9.13, and the Health and Safety
Code. S. 25532(a)?
❑y.
Yes c$ao
All roofs shall be inspected prior to any roofing material being installed.
Will thea licam or building Occupant ase a or which
tap g p
If a roof is installed without first obtainingan inspection, I agree to remove
P
emit hvardnus all canuminans u defined by the Bay Asea Air Quality Mamgcmcnt
AM. M..s
all new materials for inspection.
pisvicR Put
yes
I have mail doe hvandmastrabrods mrptiremcpu under Chapbr6.95 of Nc Califon
ma Hath&Safety Cod, Sections 25W5,25533 and 25534.1 undersold thatifthe Whoing
does not cumndy hart a tenant. Nat itis my respemihilily b mtifY Circ n¢upsnt of db
m°rim "rsw ire sea be meL 'orw "'"� gc`"if"/r'j.O
(
Signature of Applicant Date
J
All roof coverings to be Class "B" or better
O ner or auNorimd agent Oau'
• 2 ITEMS OF 2
•
•
CITY OF CUPERTINO
PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 32645028.00
DATE ISSUED.......: 12/20/2006
RECEIPT #.........: BS000000043
REFERENCE ID # ...: 06120110
SITE ADDRESS .....: 10371 MANN DR
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: ELLIOTT KATHLEEN A
ADDRESS ..........:
CITY/STATE/ZIP .... ,
OPERATOR: amyw
COPY # : 1
RECEIVED FROM ....:
RECEIPT INTERFACE
CONTRACTOR .......:
MARK PETERSON LIC
# 28456 -
COMPANY ..........:
PETERSON REMODELING
ADDRESS ..........:
235 ST FRANCIS ST
CITY/STATE/ZIP .:
REDWOOD.CITY, CA 94062
TELEPHONE ........:
(650)369-9063
FEE ID UNIT QUANTITY
------ ------------ ----------
AMOUNT PD -TO -DT
THIS REC
NEW BAL
BPERMFEE VALUATION 12,000.00
----------- ----------
19.1.16 0.00
-------
191.16
----------
0.00
BSEISMICRE VALUATION 12,000.00
1.20 0.00
1.20
0.00
TOTAL PERMIT
---------- ----------
192.36 0.00
----------
192.36
----------
0.00
METHOD OF PAYMENT
-----------------
CREDIT CARD
TOTAL RECEIPT :
AMOUNT
---------------
192.36
---------------
192.36
REFERENCE NUMBER
--------------------
VISA
FROM : PETERSON REMODELING PHONE NO. : 659 369 9063 Dec. 20 22006 02:43PM P2
•
CUPERTINO
•
•
CITY OF CUPERTINO
jai ROOF
PERMIT APPLICATION FORM
APN #
Bldg Permit Fees
Date:
O(p
Bui ding Address:
EnergyBUILDLNG
f BSEISMICRE
O er's Name:Phone
-�►te�,. V �Iv�s—
BUILDING J�
#:
(,To -2-0
Co actor. CC;;�� J� ��
1 BUILDING
License #: �
OS
Plan Check Fee
BULDING
Cupertino Business License #:
Type of Roof Covering:
Existing:
Proposed:
❑ Built -Up Root'
❑ Asphalt Shingles
❑ Built•Cp roof
�C.4>phal: Shingles
X-"�ood Shakes
❑ Wood Shake3
❑ Wood Shinglc9
U Wood Shingles
❑ Other (Specify) _--,
❑ Other (Specify)
Number of existing coverings ,.._
U provide LC.B.O. Report #
O To be Removed
U Provide Mfgr. Installation Specs.
I Have Read, Understand and Will Comply With Cu
rtino's Tear Off Policy:
Job Description:
Residential Commercial O
Fire Zone. Yes 0 No ❑
Confirmed with Planning WL if
there are any restrictions: Li
Cost of Project: Type of C'onstruclaon: Occupancy group:
b ( ZLqn 4,IgCc r'l
r✓c✓y . _ —
Qty. if
Atmlicable Fee ID
Fee Desctiotion Fee Grout)
II BPERMFEE
Bldg Permit Fees
I BUILDING
BENERGY
EnergyBUILDLNG
f BSEISMICRE
Seismic Fee Res
BUILDING J�
BSEISMJCOM
Seismic Commercial
1 BUILDING
BPLANCHK
Plan Check Fee
BULDING
BUSLIC
Business Licensc
I BUILDfNG
I