06120026 CITY•OF CUPERTINOG�NTI2AGTORIN-FORMATION
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PETERSEN-DEAN INC PERMIT NO.06120026
21698 OLIVE
OWNER'S NAME: PERMITISSUEDATE
Ask LIEBELT HERB J 7980 ENTERPRISE 12/08/2006
NE:
SANITARY NO. CONTROL NO.
(510) 494-9982
ARCHfrEC 'ENGINEM: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�0, LICENSED CONTRACTOR'S DECLARATION
Job Description
w I hereby affirm Net I am founded under provisions of chapm,9(commencing
:zwwith Section 7")of Division]of the Business and Professions Code,and my license is
<m imm112mrecande11LVaKlQ REROOF DUPLEX- TEAR. OFF EXISTING, IKO 40LB FELT
;q? License C !x.«
�o Dawy Canuano, yc�CCQ�g�f� PLYWOOD 32 SQUARES, CLASS A OR B
lan
ARCHITECTS DECLARATION— a� _
I understand my plans shall be used u public
be
)yU
tH LiamcJ Professional
OWNER BUILDER DECLARATION
i f I hereby alarm
that I am cumpt form the Canvacwr's Liccnu law for the
:CC fallowing mason.(Smuon 103 IS,Business and Professions Cads:My city or county
<w which.,.I.a pmmb m construct.a@a improve,demolish,err.,.it any loormu e
u—m pnorto its exams..also inquires the applicant far such Permit o fila asignedsummcm
door heir licensed pursuant to th<pmasianv of the Contractor's Lumen.,Law(Chap=9 Sq.Ft.Floor Area Valua$iafL 660
u�$ (commencing with Section 70(0)of Division]of the Business and Professions Cade)or
s dru M is exempt thtrtfmm and the handle far the alleged exemption.Any violation of -
Seetion 7031.5 by mr,appliant for a permit mbjeeu the app iiesm to a civil penalty of APN Number Occupancy Type
nal mart Nan five hundred dmllans($tem. 35721002 . 00
❑1,u owner or Ne pmperty,m my employes with wages u Nevxk compensation,
will Or the wOdk.md Ne momme,I not imenced moRaed far rude(Sm.7064,Business Required Inspections
and Repeated.Code:The Canureto's License Law docs nut apply w m ownee nsr of q p
pmpeny who builds or improves themon,and who doessuchwork himself our Waugh his
own employees,previa,i op such improvements are not intended maBered for sale If.
budder,,On building b r don of proving
is sold within ane year of rnmpieuoor Ne owe of
builder will have Ne burden a[pmvinB Nal k did not build our improve far purpose of
sale.).
❑1.as owner of One property,am exclusively contracting wit liaved cendamsrs to
consauct Nepmlect(Sec.7W.Business of andrty who
Code:)The ws demon.
and U.
otic law cora not apply to an owner of ovarfs who builds ren improves W roon,and
who eantneN for such pajeets with a cantraetor(r)licensed pursuant to Ne Contractor's /
l.kenx law.
❑1 am exempt under Sec. .B&P C for this moon /
OwMf Date
WORKER'S COMPENSATION DECLARATION
I hereby arTrm under penalty of perjury ane of the following declaratiou:
7CC \jfi
have and will maintain aCer ifran:of Couenl w xlf-insuce fa Worker's Compen-
a provided fm by Section 3700 of Ne labra Code,for Ne perfofmana of the
far which Nis permit is issued.
have and will maintain Worker's Compensation Iuurana,a required by Section
0 mf Ne Labor Code,fes Ne performance ofNe work for which Nu permit is armed.
WmImer C�ommpensationIttsurattce aria and Policy monitorrart:
ier. W OLLUl/" Policy NO.:I r n� � 3FICATE OF EXEMPTION FROM WORKERS'
L` COMPENSATION INSURANCE
(This sec0an reed rot be completed if Ne Permit It foram hand adoollars(SIM)
or loss.)
I century Nal in Ne perfmormace of W work far which this Permit H issued,I shall not
employ anyperson in my mannerso to,or become subject to the Workcr'Compensation
laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate or Exemption,you should
become subject to On,WoAter Compensation previsions of the labour Codc,you most
., z forthwith comply with such provisions our this pernil shall be eecmed revoked.
z "" CONSTRUCTION LENDING AGENCY
4 Ihemb aRrn Nat there is I construction lending for des
f-' Y Pagenty' performana our
C the work fur which this permit It issued(Sec.3037.Civ.C.)
GQ Lender's Name
:::?z Umd,es Address
U Q .I certify Nat 1 have read this application and state that the shove information is
(L corect.I agree to comply with all city and county ordinances and state laws relating to
O V building construction.and hereby authorise represemutiwa of this city to enter upon the,
shove mentioned property for Impecuon purposes.
y (We)agree m save,indemnify and keep harmless the City of Cupcfum against
Vy liabilities.judgments.costs and expenses which may in any way amue against mid City
U,Z, in consequence of the grmung of this permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL.E. NO -POINT Issued by:S �(4 Date
SOURC �L_
0 / f2Iy Re-roofs
Signature of ApplianUContrxtor Dow
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Neapplicmt a future iraldi.,axupant start or handle bvardoos material
u defined by the Cupertino MLa pal Code.Charm,9.13,and the Health and Safety
Cale,Section 05533(a)?
❑Ya e All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or futu building occupant Lase equipment our dcvics which If a roof is installed without first obtaining an inspection,I agree to remove
it havardous air contaminants derided by the Bay Area Ai,Quality Management all new materials for inspection.
Disvic,7
Oyeru
Ihaw rtad the hmardoInmmMalsmquimmc 5534.1rChapwrd.95ofthc Cables, ------t
nice Hes W R Saf.currently
a Wmant, ]at it is.95ll and ns53d.1 andcrwnd Incoccu c Eluding V(/
dao not cmrcndy have a senanL Nat it is my responsibility m noul'y occupant of Ne
requirements wh the erpdar w' �aa,,x o��cerdlrwaw arcs Signature of Applicant Date
—" " "' t?' oG
Owner tar autharissd engem Dam g
All roof coverings to be Class"B"or better
'
Community Development
Torre Avenue
sm CupeOrtinoCA 9014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
OUPEkTINO
Building Department
JOB ADDRESS: PERMIT #
a 70 u Vrz
� r9✓c:" 6 6 ! Z �z
OWNER'S NAME:(PW PHONE # 40ra-S`
GENERAL CONTRACTOR f FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
ba 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, y
Owner/Contractor Signature Date
CITY OF CUPERTINO
em 2 of 3 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35721002 . 00
DATE ISSUED. . . . . . . : 12/08/2006
RECEIPT # • • • • • • . . . : 36990
REFERENCE ID # . . . : 06120026
SITE ADDRESS . . . . . : 21698 OLIVE AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : LIEBELT HERB J
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-5938
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
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
305 FRAME FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•
CITY OF CUPERTINO
REROOF
CP
UPENOO PERMIT APPLICATION FORM
APN # 351 74 , 022 Date: I Z '
Building Address: e-f JP/L%frJQ 6A ^jI
65
Owner's Name: ` � SV t nn,. ' Phone v `6 55 o��a 1234(
Contractor: c� 1 License #: 6 srj , 7
Contact: /V Cupertino Business License #:
Type of Roof Covering:
I le, u o
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
.IlK Wood Shakes ❑ Wood Shakes
❑ 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: c r
JoC�>bD�e�sSiption:
Residential R Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning De t. if
there are any restrictions:
Cost of Project: Type of Construction: Occupancy group:
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
•