06120027 CITY OF CUPERTINO
BUILDING DIVISION PERMITINFUItMATIi<, N.,
SLIMING ADDRESS: PETERSEN-DEAN INC PE"" 0.06120027
21680 OLIVE AV
OWNER'S NAME: PERMIT ISSUE DATE
IAN GALLOWAY 7980 ENTERPRISE DR 12/08/2006
NE: SANITARY NO. CONTROL NO.
(510) 494-9982
ARCHITECT/ENGINEER: BUILDING PERMR INFO
.BO EO PLO MECH
�Op LICENSED CONTRACTOR'S DECLARA7ION Job Description
I I Mreby in.thrr
at I am licensed under proviso.of Chapter 9(cumewcinfl p
wAi`reanefemon�ofBeBadnwandPmtww.� myllcnQu
In full REROOF DUPLEX- TEAR OFF EXISTING, IKO 40LB FELT
r�3 Liemm Cl Dam0 Comment r,+l, PLYWOOD 32 SQUARES, CLASS A OR B
) � ARCHITECTS DECLARATION
1 understand my plans shall W.ed as public record,
°sed Licensed Professional
OWNER-BUILDER m DECLARATION
9 I Wacur .(sus that 11. exempt from the Cctiord o Licenm Law for the
p o following won.(session u 7 ommu Business and Improve.
de oli Code:My oily or count'
f$ which.quirts&permit re construcs eller,W rot such
demolish,or mash any structurenl
Z Ser
that
m its usue.p su requires;tothe ro applicant far Contractors
ontra toil mimmfile aeLawJ suvmem
zzp < thatWenikcnmcpurswnit0CiteofDivisioofthe eButtmeaLicenseLaw(CMpter9 Sq.Ft.Floor Area Valua$3fe660
d 8
(commencing I.ext with Section 70nd the
Division r the
the Business and Prormlon.My vi Cade)or
da�
that W V exempt iheac(rom and Ne b.0 far dac Wryed exemption.Any violation or 1p.{(L7�r�
S.W.7071.7 by airy applicant for a permit Suce m A
bjethe applicant a Civil penalty of Nu 0 9 . 00
Occupancy Type .
not mart than five hundred dollen(5.100). 351/21009
❑I,u owner of the property,or my employees with"sea u their role compe.adon,
will do the work.and the awcture Is not Intended or offend for sale(Sm.7044,Business Required Inspections and Professions Cade:The C.uacmes License Law does rot apply m e an owner or q p
Property who Wada aimprnvea thereon.and who da.s.h weak hinmelrarthmorh his
busem,lO Wilding
ildin i or Improvement
mprvemnot year
ofoorofftseB fres caner.
builder the have
thg.den of proving
withinamuildofImpovefortheowner-
builder will haw the When or proving Nat W did rml dtiM n Improve for purport of /
lois).
❑1,u Owner of the property,am esdunvely communing with Ilccamd mrumaora to { '+
construct ass project(Sea.7014.B.iow and Professions Cade:)The Contractors U-
cense law does sat apply to an owner of property who Wilds.,improwa ounces.and.
who contracts for such pmjew with acontracuu(s)licensed pursuant to We Contraction
License Law.
❑I sm.empt under See .B B P C for this wan
0. Dau
k1WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury om of the following ticclermlons:
have and will maintain&C Osificau of Cement to salf4arsure for Warners Compeer-
we
as provided(a by SecWn 3700 of the labor Cade.fa Cite performance of the
F,
rk for which this Peron ie ieued.
I lave and will manuin Worker,Compensation Iruunncc,as acquired by Section
7700 of the Labor Code.far the performanec of the work for which this permit Is issued. _
Ca Workers COmpenloti Ism ecartleroli Porky number��'
Cartier. Polity FROM
J
/yea CERTIFICATE OF EXEMPTION FROM WOR E
ly t COMPENSATION INSURANCE '
V Cmu Alan need an,W campicted if the permit is frame hundred dollars($100)
or leu.)
I certify that in the performance of the wart for which this permit is issued.I shall red
employ any person in any manners,as to become subject to the Workas'Canpmlotion
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become Subject m the Workers Compensation provisions of the Labor Code.you am
wJ O foMwith comply with such provisions or this permit shall W accrued awkcd.
zr ' CONSTRUCTION LENDING AGENCY
Fv u 1 hereby affirm that them is construction lending&ga y for the performance of
�i Ne work for which this permit is issued(Sec.7097,Cih,C)
QLarches Name
O z Lenders Addw
U O 1 certify that 1 have read this application end tum Nu the W.information is
(y comcct.I agree to comply with all city and county ordinances and sum laws misting to
�U building construction,and hereby authorim rtPtcsematives of this city m enter upon ft[LI shuvc.rntra oncd property for inspection Purposes.
la. (We)&pore to love,indemnify and keep harmlw the City of Cupenina against
cn li&biliti.,judgmenu.cow and upensea which may In any way amue.flaw sad Cly
U z in consequence of the flowing of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date / (!
SOURCEI�REE�,iULAPpONS, p 1 -
/n C� I'id�'. 12J fel Re-roofs
Signaturetppliamconuxmr r Date
HAZARDOUS MATERIALS DISCLOSURE. Type Of Roof
Will the applicant ar fuLT t"`flg accupset nam or ha ndlehavallo.m&mial
u deR.d by the Cupertino Mun ipal Cade.Chspur 9.13.Sud the Health and Safety
Code,Section I5172(a)7 Na All roofs shall be inspected prior to any roofing material being installed.
❑Y.
w se thc.pplk ant a,mom ildlnfl daupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hsurdnua ter canumi0. _ ad by the Bay Area Air Quality Management all new materials for inspection.
DiatricG
❑Y.
1WscreW
nuSan JachO.Soc lu 25505urequirtm1a0n5u7u4m.k1 rmCMPter6thiffthpehWilding
Jos ON currently MW&=et der It u myresparttbllY to oreiry / /Y�//E./✓l�_
use occupant of the _
requirements�h'hon its met ri�W`'ivanceaf&Certifcateof0aa Signature o Applicant Date
,C7 p'o �� 12�+r�O V All roof coverings to be Class"B"or better
Owner or mthortred steel Data
Community Development
10300 Torre Avenue
J Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
46UPEI�TINO
Building Department
JOB ADDRESS: 1 t (PYO 9 t o 1 (o-T$ eU u& -AQ PERMTr #
e PS2T1 h10 CA- g 5 1 9 - rL 6 D L
OWNER'S NAME: AeUGbW ek su PHONE # d Sq2- v34Cv 4 u .255 I
GENERAL CONTRACTOR Q frC rt Sty,J FAX #
I am not using any subcontractors: 4-� / Z`e1,:;::-
Signature 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
em 3 of 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35721009 . 00
DATE ISSUED. . . . . . . : 12/08/2006
RECEIPT # . . . . . . . . . : 36990 '
REFERENCE ID # . . . : 06120027
SITE ADDRESS . . : 21680 OLIVE AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA
OWNER . . . . . . . . . . . . : IAN GALLOWAY
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : PETERSEN DEAN
CONTRACTOR . . . . . . . : PETERSEN, JAMES LIC # 14030
COMPANY . . . . . . . . . . : PETERSEN-DEAN INC
ADDRESS . . . . . . . . . . : 7980 ENTERPRISE DR
CITY/STATE/ZIP . . . : NEWARK, CA 94560
TELEPHONE . . . . . . . . : (510) 494-9982
•FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 13 , 000 . 00 201 . 96 0 . 00 201 . 96 0 . 00
BSEISMICRE VALUATION 13 , 000 . 00 1 .30 0 . 00 1 . 30 0 . 00
- ------ ---------- ---------- ----------
TOTAL PERMIT 203 . 26 0 . 00 203 . 26 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
OTHER 609 . 78 MV
TOTAL RECEIPT : 609 . 78
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
•
. - OLol2c�nZ�
CITY OF CUPERTINO
REROOF
CUPEkTINo PERMIT APPLICATION FORM
APN # Date: '2 & 1 o
Building Address:
aIwo k a,U?K ou u;E Ave c„?e2%(Ao CA RSr o's-
Owner's Name: ,\ ^ 1 / l A
MPhone #: ti(pb a i
fN�
Contractor: E=S-JzSz–rJ '� —AN License#: 4600611 ' 7
Contact:
LGY4Nb2o M C1LCA-z),=> Cupertino Business License #:
Type of Roof Covering:
11cp %.lo
Existing: Proposed:
❑ Built-Up-Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
-X Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings Cl Provide I.C.B.O. Report#
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
'41
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: C
LOC6:5-,on: [7, 010r� �1� fir, –� �J ?2 S�J
Residential -K Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Dept. if
there are any restrictions:
Cost of Project: _ Type of Construction: Occupancy group:
12acZ-�o F S�t-P
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
•