06090113 CITY OF CUPERTINO ti 'w Nig r iia t
BUILDING DIVISION PERNIIT +a ONIC121 CT�n' RINFFO Q `•
BUILDING ADDRESS: CONSTRUCTION INC PERMITND.O6O90113'
10453 MARY AVE BLD H
OWNER'S NAME: FERMD ISSUE DATE
PACIFIC STATES ASSOC. SERV CES605 COMMERCIAL ST 09/15/2006
NE: SANITARY NO. CONTROL NO.
(408) 536-0420
ARCHITECrMNGINEER: BUILDING PERMIT INFO
BLDG ELECT PWMB MECH
�oo LICENSED CONTRACTOR'S DECLARATION Job Description
uU1 1 bomby afford p
Net 1 are licensed under provisions of Chapter 9(mmmem(ng p
with Seeman 70118)mDivision 3 of Ne Business and Profeum i. Coda,and my license is
nrdllfomeaM REROOF- UNITS 10453-10463 BLDG: H
'qz Lamm I a rag TEAR OFF EXISTING INSTALL 2 LAYERS OF 30LB FEL
i- Date Coatre<Nr r
ARcxITECTs oECuannoN - UNDERLAYMENT, 40 YEAR COMP SHINGLE & BUR. 100SQ
i�< I nticrannJ my plain shall M used u public mrnrds
j6G
Licensed Pmfcuional
rm5 OWNER-BUILDER DE Me COnUION
0 f I noun .affirm(Sec that I I.S.exempt from the ConaaeCas License Law far ale
•e o fallowing moon.(Section 713 LBusiness and Pmfemiom Cade:Any city or County
I9(Li which requires a permit to national on the alter.Wpnw,demolish,ar mash any wunum
primmimcensedam&nL Alan 10Me Novismoranl for such permit m rile a cense Lhadmtamcm
< dm mend gwiaSccUn 7")amvisi ion3of ContrumfndPmLaiomC(Chapter)9 Sq,Ft.Floor Area Valuation
(eommes exempt
for
alleged
euendon.m vi Code)ar $104000
Cat he h exempt therefrom and the buss far Na aIle{od nemption.My Wolation of
Section 70313 by any applicant for a permit objects the applicant to a civil penalty of AFN Number Occupancy Type
not more Nan fro hundred dollars,(g500). '
01,ua ofthepwmty,wmyempkay wMwagnu Neirwlecompe don,
will do tho wing,ands: shueurehme Licanc oraMandwda m not apply 70N,comer of j}jgD Ct10DS
aM do Me lam Code:The Camanmfa Linme Law don not apply o an owhar of 'Injj��r��
property who Wilda aimpro.a Nerean,andwho Enessum warkhhmsuuor through Na
own employees.provided Net such improwmenu sm an,Widened maffered far tela If.
hawem,,Ne building or Improvement is said within am wan ofcompledon,the owmr-
builder .MO low Me Wrdm of pmNng that he did Out Wild or improve for purpose of
xi '�►� 2s 2001
C31,u owner of the property am exclusively contemn[with licensed Contractors In
construct La Ne pmjed(Sec.7044,Uner of and property
who m Cade:)The Cmhumr'a d t!I ��
eeme law don not such
lean owns of Property who WIWn mimpro.s Coulon.and, HpgiVlt§Ig
who canasta for such projects WIN a mnasstarts)Earned pvrawm m Me ContrenoYs
License Law. 1 \\4{
❑IamnemptunderSee ,BdPCfor Cismuon JJJ WWW
OwnerDau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing declanaam: '
1 ham and will maintain a Certificate of Consent to self-Imam far Worker's Compen-
ution,u provided for by Section 3700 of the Labor Cade.for the performance of No
work for which Nis permil is headed
1 Mw and will mainuin Workees Compensation Insurance,as inquired by Section
3700.17 Ne Labor Code,for Ne performance of Ne wok for which Nu permit h issued.
My Warkefs Campemui Insurance artier and Polity num-baer are:
Carrier.E Polity HUM 1�04IC
CERTI ATE OF EXEMPI70NFROM WORKERS'
COMPENSATION INSURANCE
Crhic seetim hand Out W completed Bthe permit Is foram hundred Callan($100)
ar less.)
I certify,Net in Ne performance of the work for which this pertrdu Is Lured.I mall an,
employ any Person in any manner an an to bcmma subject in the Workms'Campemalion
Laws of CllifomiL Data
Applicant
NOTICE TO APPLICANT:If.efair meting this Ccnificata of Exemption,you Could
become subject N the Workefa Compensation prevision,of the Labor Code,you mon
.,O forthwith comply with such provisions or this permit shelf W deemere
d mked.
zW) CONSTRUCTION LENDING AGENCY
[n I hereby alarm thea Nem is a construction leading agency,for Ce performanceof
Ni
the work for which this permit is Lund(Sec.3097,Civ.C.)
W� Q Lendoes Name
z Undoes Addmu
U C) 1 cedify Cat I haw mad this applicnim sodium than Ne also.information hs
U. "" correct.I agree w comply with all city and county ordinances and mule laws mudng in
0 U building construction.and heathy authorim mpmsamatis of this City 10 enter upon the
LTJ show memi..ed property for inspection purposes.
L>, (We)agree lou.,indemnify and Imp harmless the City of Cupertino against
liabilities.judgments,costs and expenses which may in any way acme against mid City
U,Z, in comer moa of the gonlin{of this permh.
•^ APPLIC NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: �60 Date `57— uiax lj�
SOU LATI
9i Re-roofs l'
Signed..of ApplicanhCamrxmr Done
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dieapplicantor,future Wildhng accupam on,orhandle haurdou material
as atoned by Me Cupertino Municipal Code.Chapter 9.13,and Ne Health and Safely
Code,Section 35531(.)7All roofs shall be inspected prior to any roofing material being installed.
41 ❑Yoa u
Will the applicant ar Comm Wildin aaupaat use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit ha„rdaaa air cmmmiaanu as act d by Mte Bay Arta Alr polity Management all new materials for inspection.
District?
❑Yn a
Iban read the luxurious HmawundcrChepterd.93 ofthe Gl
nuHCBAfeys255D533nd75534.1 n ifuor
dbuilding
Jan not currently him a unnam.Met it 6 myampenshiity in maily the omcuperr,ofa
mquim uwh' ahem prior m' ( fuataaroma y. -Signature of App icant Date
O ncroreutharire ill ta' All roof coverings If be Class "B"or etter
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
4JUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
OWNER'S NAME: &"F:tS4Ewjcev% PHONE #y0 -
GENERAL CONTRACTOR FAX # y0$-$3
I am not using any subcontractors: 1 � —� / Colo
ur
Signate 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
�m 1 of 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32652069 . 00
DATE ISSUED. . . . . . . : 09/15/2006
RECEIPT # . . . . . . . . . : 36055
REFERENCE ID # . . . : 06090113
SITE ADDRESS . . . . . : 10453 MARY AVE BLD H
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PACIFIC STATES ASSOC. SERVICES
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
�EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
--- -- ----- ------------- ---------- ---------- ---------- ---------- ---- ------
BPERMFEE VALUATION 104 , 000 . 00 868 . 32 0 . 00 868 . 32 0 . 00
BSEISMICRE VALUATION 104 , 000 . 00 10 .40 0 . 00 10 . 40 0 . 00
------=--- ---------- ---------- ----------
TOTAL PERMIT 878 . 72 0 . 00 678 . 72 0 . 00
•
n� P005
CITY OF CUPERTINO
0-c REROOF O
CUPEkTINO' PERMIT APPLICATION FORM
AP Date: �ZI
Building Address: ff '' tt ``
M 5s— O"I
Owner's Name Phone #:
zA%Soc. s2ky-1w; �� -8�S 9►�o
Contractor: License #: `-
Contact: Cupertino-Business' '
Type of Roof Covering:
Existing: Propos
❑ Built-Up Roof m/Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
❑ Wood Shingles '�.�-� ❑ ood Shingles
Other(Specify) el m/Other(Specify)
Num�er.of exits^ting coverings ',.-' (�; a ❑ Provide I.C.B.O.R�# VVV
Y To be Removed 'u� ❑ Provide Mfgr.Installation Specs.
r
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description: of- 3 F-F,, %t_n �—
V 9b
Residential Com ercial O
ire-Zoi*7 YesE]'No- ----Z Confirmed with Planning Det. if
there are any restrictions: LJ
os ) Project: Type o Co struction: occupancy-grou
D I
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
•