05100213 CITY OF CUPERTINO '
BUILDING DIVISION PERMITC'ON„TRl1
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BUILDING ADDRESS: DRAEGER CONSTRUCTION INC PER ""051OO213
11315/10317
OER'S NAME: PERMIT ISSUE DATE
PACIFIC STATES MANAGEMENT 605 COMMERCIAL
NE: SANITARY N0. CONTROL NO.
(408) 536-0420
ARCHITECr/ENGINEER: BLDG BUILDING PERMIT INFO
ELECT PLUMB MECH
l� l�
jo0 LICENSED CONTRACTORS DECLARATION 'lob Description
1 hereby.M.Nal I am Veered.oder provide-or CTePmr 9(ammoncing
with Section?0011)of Division 3 ofW Business arm ProWsiou Code,arm my lkemeis
mfatlfomomdeff (Q t402 1
p REMOVE (E) ROOF-INSTALL 40 YR COMP
x Lkanw Cl `-3`� Lk.,S
Camada SHINGLES 5 YR PLY CAPSHEET
?ey' rrEcl's DEC".TION �•
Yqu 1.M w.dmypWns MWheusedupublicmorb
s KKKK� Licensed Professional '
b OWNER-BUILDER DECLARATION
i7 1 hereby affirm that 1 am eumpt from Jon Conuutofs license Int for the
p O following mason.(Section 7031.5,Busies and Professors Code:Any city or county
5@O! which requi es a permit m conasuect,alcor.heprove,dmWRo.or mpmr any soc um
iy priorm its hommee.also requites tho applicant fW=h permit to file a Signed aummem
that he is llmnud pursuant m the proviaNaaf WC(m um"license law(Chapur 9 Sq.Ft. Floor Area Valu$IbiD OOO
�g (commencing with Section 7000)of Division 3 of the Busirca"ProfaWou Code)of
that he Is exempt therefrom and We but,for the alleged esempthon.My violaum of
Semim 7031.5 by any applicant for a permit objects the applicant re a civil penalty of N Number Occupancy Type
rot mom inn five handed dollars(M). 3 2 6 52001 . 00
Q I,as owner of the property,or my employees with wags as their min campers ut
will do the work,and the awcmm is an,Weeded car offered 1-112k(Sm.70th,Busircu Required Inspections
sed Prnfesmoua Cede The m
Conuaefs License Law does ant apply W an owner e of q p .
property who builds or improve,Wrem.and who dm such work himseifOr Waugh his
own employees,provided Nu such impmeoenu me nut imWed nes@rod for file U,
however.the building or improvem on Is mid within on year ofcompledon,W owner f
builds,wtH have the burden of proving that he did ma bmk or improve for purpose of
❑1.an awmf of the SM 704,.B esclusivnd conbsethng with:)The
rmosees -
Oman La tido does
(Sect Os,,Beskm and rcy who Wild,
Code:)Tim Cove rman.LI•
moa law dao not apply m an ower of propertYwmo heika ar Mpwve,Wotan.and, -
Lwho ketentacle for such pm)eN with a canuanar(O0ansedpurewnl se W Contractors
❑Ise exempt under Sec .BhPCfor NW maven
Data
WORKER'S COMPENSATION DECLARATION
1 hereby all=under peuily of perjury am of Ne following deciamdow
❑I have and w01 maintun a Ceninau of Consent in self-Wort fm Work esCompeo-
Wim.as provided for by Section 3700 of the Ube code,for We peffom oca of the -
work for which this pcmlt Is Wood.
❑1 have and will maintain Wmkefs Compensation Insurance,as required by ScWw
3700 of W Labor Code,for the performance of W work forwhich this permit Is iamd.
My Worker's compensation bnurana artier and Policy num
Grtier �C1�,O��- Policy ��U o
CERTIFl TEOF N FROM WORKERS'
COMPENSATION INSURANCE
Miser as need Out be cmplemd Ude permit Is form hundred"m($1001
at lcsa)
I certify that in tie performance or the work for which this permit W Wood.l Mall rot
cmpluy any person in any mmlmrse as an become, abject u tho WQd=d Compensation
Laws of California.DW
Applicant
NOTICE TO APPLICANT:If.attar making this Cemfiau of Fsemption.You souk
become Subject in the Warkeh Cermpcuaatinn provisions of the labor Cade,You mm
.J O forthwith comply wild such provision m thin pemil Mall he deemed revoked.
z' CONSTRUCTION LENDING AGENCY
`
F (hereby afftm than dem Isaauaucthon lenNng agency,for the perfomamm of
lx> the work for which this Permit Is Issued(Sec.3M7,Civ.C.) '
Q Lender's Name
=z leader's Addfem
L)O I certify Wat I have nod this applleuion and sum the the above lo(alntation t,
ty^. mmt=I agnm u empty with all city and moray mNnances and abuse Wes Rising u
O rV^ building construction,and hereby authorice representatives of this city mcmer Open Ne
L27 shove-mentioned propcny fer inspection purposes.
0. (We)agee in nve.Mentally ad keep harmless Jon City of Cupenino Assoc
Vj liabilities.judgments.eau and expenses which may In say way accrue.,.in[old City
t.)Z ineonaquence of the gryNng a(NIs pemit
^ APPLICANT UNDE ANDS ANdDALN D 1 OMPLY WITH ALL ON-POI Issued by: Date (]Z�"a 4'
SO RECULATI
)m 0 Re-roofs `
Signuuw o(Appllnuacmr Dae
IAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appliant or(utm building accupalearo"andle hamdow material
u de0ecd by W CupeNno Municipal Code.Chapter 9,13,and W Health and Safety
Smkm 25532(1)7 All roofs shall be inspected prior to any roofing material being installed.
El Y. I�7No If a roof is installed without first obtaining an inspection,I agree to remove
Will Ne applicant or ffutture building occupant use equipment or devlm which
emit haardous air contaminants as defined by the Bay Ama Air Quality Management all new materials fo ' pection.
Disuier7
❑Ya ®Nu
I haw read W hazardousma¢naWequlfenmwumlcrCapter 693ofW Califor.
nix lkalm k SakyCode,Sections;25305,255 and 253M.IunJcnuM thmiftho WilJWg
MJJLO
Jm cumntly hew a t,than it uihII11Y m onthfy W Mau I=
Ne
regal ntawhichmtm Sol af=rmamof Signature of Appi a Dat
0 0 All roof coverings to be Class"B"or better
Ower or auNarveda m am"
Community Development
-'f10300 Torre Avenue
Cupertino CA 95014
£4Telephone(408)777-3228
nC�T I A I O Fax(408)777-3333
f C 1 ISI Building Department
JOB ADDRESS: PERMIT #
0 15 -1 b 31 Y`(`o_ five $ A 1 4 s-i 00 2 3
OWNER'S NAME: - PHONE # Lj -S -0 aU
GENERAL CONTRACTOR: paw C FAX # Ljn -36-pyla
I am not using any subcontractors: /0
S1 ature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing .
Roofing
Septic Tank
Sheet Metal
Sheet Rock
• Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
2 of 2 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: 'Sub: Blk: Lot:
APN . . . . . . . . : 32652001.00
DATE ISSUED. . . . . . . : 10/27/2005
RECEIPT #. . . . . . . . . : 31755
REFERENCE ID # . . . : 05100213
SITE ADDRESS . . . . . : 10315/10317 MARY BLD A
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PACIFIC STATES MANAGEMENT
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
RECEIVED FROM . . . . : DRAEGER CONSTRUCTION
CONTRACTOR . . . . . . . : DRAEGER, JOHN EDWARD LIC # 21895
COMPANY . . . . . . . . . . : DRAEGER CONSTRUCTION INC
ADDRESS . . . . . . . . . . : 605 COMMERCIAL ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95112
TELEPHONE . . . . . . . . : (408)536-0420
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
.__________ _____________ __________ __________ __________ __________ __________ .
BPERMFEE VALUATION 10,000.00 169.56 0.00 169.56 0.00
BSEISMICRE VALUATION 10,000.00 1.00 0.00 1.00 0.00
__________ __________ __________ ----------
TOTAL PERMIT 170.56 0.00 170.56 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ------------ ___-__-____-______
OTHER 628.16 VISA
TOTAL RECEIPT 628.1 6
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•
10/26/2005 08:39 4088859125 PACIFIC STATES PAGE 02/02
r ACIFIC
• STATES
MANAGEMENT COMPANY
2510 Stevens Creek Boulevard <
San Jose,CA 95128
Fax: (408)885-9125 "^
(408)885-9160
October 26, 2005
City of Cupertino
Building Division
Re: Casa de Anza Homeowners Association
Re-roof Project- 2005
To Whom It May Concern:
This letter is to confirm that Pacific States Management, as a representative of the Casa
de Anza Homeowners Association, has authorized Draeger Roofing as the chosen vendor to do
• the re-roofing project for the A & G buildings (10315, 10317, 10465, 10467, 10469, 10471,
10473, 10475, 10477, 10479, 10481 and 10483).
Please feel free to contact our office if you should have any questions or need additional
information. We will be more than happy to assist you.
Sincerely,
Pacific States Management
e U�Tara Jolley
/ 4z l/
( Oar
27 2005 /
TJ:sI
Board of Directors
File
r. .
CITY OF CUPERTINO
REROOF
• CUPEKTINO PERMIT APPLICATION FORM
APN# a710 SoZ dd/ Date: O a(.A0
Buildd i ddress: O�I�
3 MOIrAvc vh,A
O=:me: Phone #. n 1�0
S teS e.Yne AI /+o —9&S-_1
Contractor: Ij License #:r_
Contact: Q Cupertino Business License #:
Wal 90 9-5-66-I4ao I
Type of RoofCovering:
Existing: Pro osed:
❑ Built-Up Roof Built-Up roof
❑ Asphalt Shingles Asphalt Shingles
❑ Wood Shakes - ❑ Wood Shakes
❑ Wood Shingles � � � El Wood Shingles
YP Other(Specify) +0,f-b '(�0 Other(Specify)_
Number of existing coverings ❑ Provide I.C.B.O.Report#
Cl To be Removed ' ❑ Provide Mfgr. Installation Specs.
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description:
i Sin (bD� nS l� oLtcQ �t �J
Residential 1AComm tial ❑ -
Fire Zone: Yes ❑ No Confirmed with Planning D�t. if
there are an restrictions:
Cost of Pro' co Type Co truction: Occupancy group:
Q
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
/ BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
•