06120025 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 0,
BUILDING ADDRESS: PETERSEN-DEAN INC FERMI I NO.06120025
OWNER'S NAME: PERMITISUEDATE
IAN GALLOWAY 7980 ENTERPRISE DR 12 /OR/2006
NE: SANITARY NO. CONTROL NO.
(510) 494-9982
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLOC EO PLO MECH
�oo LICENSED CONTRACTOR'S DECLARATION lob Description
i b i hereby affirm Nns at I am licensed under Provisions;of Chapter (mmmereMs P
qiwith Secdon70()ofDivision3ofLha Businm nd Profcuiun,Cada andmylkenseis
License anaertet q Lcg REROOF DUPLEX- TEAR. OFF EXISTING, IKO 40LB FELT
Dam contractorDECL
PLYWOOD 32 SQUARES, CLASS A OR B
As shall use DECLARATION
I understand my phos shall he used as public records
r W.
•G Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby so shim that 1 1. mumps s a me Pr Contralessmeetofa License Law per me
O o following reason.(Section]031un, t.Business and Improve,
de ons Cale:My city m county
f$ which rogWres a issuance.permit sho la a lour ft plan impmw,m permit I.ri mash any udemere
•Iry^ met is ice ensedpm requires ted apions o for such permit musics Law(suumul
< Bm"rouncing wit pursuant lone of Divioruofine COnuineslnd Poar Law((.7upur9 Sq.FL Floor Area Valu iIDQ660
g{ B d at he Ls with t S=dbcmf 700 d basison 3fw t the Business and per.Arynvi Codc)lagan sir
mal he u exempt Ibucnom and Ne basis for Ute alkgm exemption.My Molation of
Section 7031.5 by any applicant for a permit subjeeu the applicant to a civil penalty of APN Number Occupancy TYPe
not mom Nen nw l uedred dotlan(S500), 35721011 . 00
❑Lasowacrofine property,amyemploym with wagesutlteuhak compvwtim,
wiudo Newark,andtheauuctumurmtimm.dedoraRerealoraaie(Sm.70/a,Bunttm Required Inspections
and Profession,Cedm The Comm emes I lame Law does,ace apply N an Mv—of 9 P
pmpenywlm Wilde mimprowathereomandwha
within
akaussuchavarkmvdfor through his
emprovided maehimprowm ant not intended"offered f,
Imm .the Wilding
oriommt4halt withinoyear,ofmapledon.the
power.
builder will have the burden of proving,that M did not Mid or improve for puts=of
sale.).sale.).
4 .
❑1,as awett of ct property,am exclusively concessions with licensee mosrsser's U.mass at the project Pply]os,+,amer of and rty who
cam:)TW Conoacmt,u- /
«nse lcaw noes rot apply man owacr of psapeny wed Wika m W t W the menton,and.
whocontractsLace for such projeN with amnuasior(a)licensed pursmnt m the Conuanura
License IJW.
❑lam tempt ansa See ,BhPCfor Nis mason
Owner Dau
W1WORKER'S COMPENSATION DECLARATION
I hereby&Bhm under parody of perjury one of the following decimations::
ham and will normal.a Certificate of Consent self-Inas for Wofte.Compam.
snion,an provided for by Section 3700 of du Labor Code,for Ne performance of the
wo for which this permit u issued.
I have and will maintain Wakefa Compensation Insurance,as required by Section
37M.f the Lubar Cods,for the perfonnanceaf Ne work for which NU R.I,is Wood '
My Worke s.CAompemadan.In-wp1 nce artier and Policy number are: .�'']�
Cartier. C a k fled Porky Na: C a, 03
C�u��FgT SCATS OF EXEMPTION FROM WORKERS'
NL COMPENSATION INSURANCE
Inds section aced ons be completed If ft permit is for one hundred mllara IS I00)
or IaA)
I wily Out in the performance of the work for which this permit I$issued,l uuil trot
employ any person In any manner so as to become abject m the Worker6 Compensation
Laws of California Dau -
Applicant -
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to Ne Workers Compensation provisions of the Labor Cam,you mug
,JZ forthwith comply with such provisions or this permit shall W deemed revoked.
OCONTMUCTION LENDING AGENCY
[-+ Ihereby&Ginn mat mem is a construction lending agency lnr the perfrommou of
a rt me worts for which this;permit is issued(Sec.3097,Civ.C.) '
Iq 0 Lender's Namc
Z Lender's Add.
U0 I cu0fy that I have read this aFi liatm.and suss that the wo.infomutiun Is
ly P carted.I agree to comply with all city and county eminences and scale laws matins to
QU building cons.6m.and hereby authorise mpmsenca.I.of this city on cuteruron me
LTa above-mentioned pmperty for inspection purposes.
gy (We)agree to sae,indemnify and keep harmless ted City of Cupcnina against
rA Ilabllitimjudgments.cow and mucuses which may in any way acerac against said City
U 7 in eansoMmm,e of Ne granting of Nu permin - n
FD APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date t.
SOURCE R OULATTQNS,
f2dYLAI Re-roofs
Sianuure of pplium/Conuasior Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof .
WIII Ne applicant or future building occupanutore or handle hazardous material
as defined by the Cupertino Muni I Cade.Chapter 9.13.and ted HanIN and Salm
Cade,Section 255334)] All roofs shall be inspected prior to any roofing material being installed.
Dyes Na
WIII me applicant or future 'I ins aecupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil hmamom air mnum musts defined by the Bay Area Air Quality Management all new materials for inspection.
WuicR
❑Yes u
Ihaw&Safci Code,She at6.255ialsmquimme5534.1rChapterQ ifthc Caldor- �� I
alk Healthk5efely Cade,Mount,ft,
3myram125534.1 Inm taffy muffthebuilding
Jas,net curtcMy have a amok Not it u my responsihllity m ratify th ac'upmt of me
requimmenuwhle tau met pd Ism earl eeniBeek at
of Occupancy. Signureof Applicant Date
Owner or uuthorixcda ent new
All roof coverings to be Class"B"or better
M
CITY OF CUPERTINO 2� 5
�K - t�. , REROOF
• CUPEkTINO PERMIT APPLICATION FORM
APN # 1131061� ' JO I ' Date: 1 2—
Building
Building Address: t (a r" r a 1 (o $ \ 1
a �. Oc,• � A� evPcrrt��o Cq- SS,o�
Owner's Name: S j Spm Phone #: N L)V S S t-/' (�1
\ A4" CPpt.l 0 w 40Y c)3(4(e
Contractor: License #: 4 (I'S- It 7
Contact: Cupertino Business License #:
Type of Roof Covering:
11Lo "i ;>
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
13e Wood Shakes ❑ Wood Shakes
Cl Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O. Report#
❑ To be Removed ❑ Provide Mfgr.Installation Specs.
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
,ob C 4-S.SA
Description: kb �
Residential f!r Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are any restrictions: LT
Cost of Project: I I�Type of Construction: Occupancy group:
I cr2 > 5�� l
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
•
£ Community Development
e 10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CI OF Fax(408)777-3333
16UPERTINO
Building Department
JOB ADDRESS: l (v f5 it a 1 L �5(a OUTS A PERMIT #
LAr C1 5%
OWNER'S NAME:\M1 SQS� &C04At-,1j PHONE #t(0�- 92Q cE YJtS d5 4u�
GENERAL CONTRACTOR V'[61,SE64 bS4^j FALDX #
I am not using any subcontractors: 49ELZ=— c lL`Fr4`2'
-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 J
• Aj—�
Owner/Contractor Signature Date
CITY OF CUPERTINO
1 of 3 PERMIT' RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35721011 . 00
DATE ISSUED. . . . . . . : 12/08/2006
RECEIPT # . . . . . . . . . : 36990
REFERENCE ID # . . . : 06120025
SITE ADDRESS . . . : 21688 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
IREE 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
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
•