06120163 (2) CITY OF CUPERTINO
aU1LDiNG DIVISION PERMIT CQl RACTC�R INw.E`ORMATIO
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME; A
M & C ASSOCIATION MGMT 605 COMMERCIAL ST 12/21/2006
NE::VVT rT IV SANFARY No. CONTROL NO.
(408) 536-0420
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�e LICENSED CONTRACTORS DECLARATION
0 o Job Description
w
$g wiNSm1 hereby m
arm Net 1 am liccmed under provisions of Chapter 9(commencing
Ition7qXl)ofDivisIon 3aftheBusinessand ProfcssionsCode,and mylicense is REROOF MFDWL GARAGES- TEAR OFF EXISTING, INSTALL
in full force and c�c'
,qz m clma Lk.g NEW 3/8" CDX OVER EXISTING 3/8" CDX NEW 5 PLY TAR
Dam
iF Dam •/l "kn Contractor
qq T� AAs shall ECTS DECLARATI & GRAVEL BUR.
�2 a 1 undemmnd my plans shall he used as public records
�yU
°C H Licensed Professional
OWNER-BUILDER DECLARATION
<f 1 hereby affirm Nal I am exempt from Ne Ccuumemrs Lice...Law for We
p O following reason.(Section 7031.5,Business and Professions Cods:Any city or county
which require a permit to canslrant,arm,,improve,dcmeiLsh,or repair any structure
prior to its issuance.also requires the applicant for such permit to Ole a signed statement
< thatboislieevdpursuanttathcProvisions ofWeConWmIm'1LiceneLaw(ChnPtm9 Sq.Ft.Floor Area $2381 Valuation
eIQ (commencing with Section 7000ess)of Division 3 of the Businand Professions Code)or
" that M is exempt therefrom and We bub for Ne alleged exempdon.Any violation of
Section 7031.5 by a"applicant for a permit subjects the applicant m a civil penalty of Number Occupancy Type
not more Nan five hundred dollar(5500). 32652031q.
❑I,an owner of tW property,m my employees with wages as their sole compensation,
will kid thewonkand Wetmore 4 mummndcl moQered fmad.sec.7044,11usiness Required Inspections
and Professions,Code:The Contractor's License Law dam not apply m e ns an owner of q p
property who builds m improves thereon,and who dma aitch work him W f or ilmugh his
own employes,provided Nat such improvements are not intended oroRered for We.If,
however,We building or improvement is sold within one year ofcompletion,the owner `
builder will have the burden of proving Nat he did not Mid Or improve for purpose of
mm,).
❑1,as owner of the property,am eaelmively contracting with licensed comm ctas m
construct the pmjcet(Sec.7044.Business and Professions Cade:)The Contractor's U.
come Law dean not apply to an owner of property who Wilds or improves thereon,and
who contracts for such projects with a conuemr(s)licensed pursuant to the Contractoes
License Law.
❑1 am exempt under See ,B k PC for this=on
Owner Dae
WORKER'S COMPENSATION DECLARATION
I y air,.under penalty of perjury one of the following dech nthrom
:m and will maintain aCanifinm of Cement to self-usum far worker's Compen-
sation,as provided for by Section 3700 of the Labor Cade.for the performance of the
work for this permit is issued.
ve and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued,
My Workers Compensation Ir ance"snjartier and Poly No.;number 3 Q6 D��
Carver:V/7%G`tiLiV "icy No.:
CERTIFICATE OF EX MPnON FROM WORKERS'
COMPENSATION INSURANCE
Tail section need notbecemplced line e Permit is for one hundred dnllan(SI W)
or less.)
1 cenify Me,in the performance of the work for which this Permit is issued,1 shall not
employ any person in any manner¢as to become subject to Use Workers Compensation .
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to We Worker's Compensation provisions of the Labor Code,you most
.J O forthwith comply with such provisions or thin permit shall M deemed revoked.
,Zs'7 CONSTRUCTION LENDING AGENCY
(r IherchyafOrm Nal then is acortswctinn lending agency lar the performana of
a 7 Ne.,it for which out permit Is issued(Sec.3097,Civ,C.)
W�Q Lender's Namc
:D z Lender's Address
J 0 1 cenify Nal 1 have mad this application and sate Nat We above information is
ry torten.I agree to comply with all tiny and county ordinances and sum laws mlating to
OU building consuunion,and hereby aubmim representatives of this city to enter upon the
W ah.ve-menounud Property fur inspction P,gmecs.
pyt (We)agree to save,indemnify and keep harmless the City of Cupertino against
,Fa N liabilities,judgments,costs and expenses which may in any way same against saidCity
U in consequence of Ne grunting of this permit.
APPLICANT UNDERSTANDS AND WILL PLY WITH ALL NON-POINT Issued by: Date
SO R R 0
Re-roofs
Signature of Appliun nmacmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will We applicant Or future building occupantnom arbandle Mandow material
as defined by.the Cupertino Municipal Code.Chapter 9.13,and the Health ad Safety
Cade,Section 35533(x)? L9w/ All roofs shall be inspected prior to any roofing material being installed.
Ym
Will the applicant or future building occupant use equipment or devices which If aroof is installed without first obtaining an inspection,I agree to remove
emit hav❑ydba,air om ands, u defined the Bay Area Air Qualily Management all new materials for inspection.
District?
❑Yes
I have mad Me hatand..nmeruds requirements under Chapter 6.95 or the Cabror.
ria Healthumend yCadc.Scctiom 355f15,355JJ am1355J4.lundcrsend lhuifthc Wilding [—l/ones not not currently have a mm m.Nat it is rrapmnxMUl,1Y m retry We occupent of Ne
mqw taw h ustbemelp%r ts ton utoroccapancy. Signature of Applicant Date
Owner or authorix ages Dam All roof coverings to be Class "$"or better
CITY OF CUPERTINO ,
• 2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: amyw
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32652031 . 00 .
DATE ISSUED. . . . . . . : 12/22/2006
RECEIPT #. . . . . . . . . : BS000000097
REFERENCE ID # . . . : 06120163
SITE ADDRESS . . . . . : 10377'-MARY-AV
SUBDIVISION . . . . . . ..
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : M & C ASSOCIATION MGMT SERVICE
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1342
RECEIVED FROM . . . . : RECEIPT INTERFACE
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 2, 381. 00 83 .16 0. 00 83 .16 0. 00
BSEISMICRE VALUATION 2, 381. 00 0.50 0. 00 0 .50 0. 00
TOTAL PERMIT 83 . 66 0. 00 83 . 66 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- - -------- ------------
CHECK 83 . 66 101358
--------------
TOTAL RECEIPT 83 . 66
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
305
-------------- -------305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•
CITY OF CUPERTINO aoaoj( 3
CLJPFRTINO PERMIT APPLICATION FORM
3au -J52- -031 Date:
llldlll1
N1,111IQ
f—
Phone
Conti ictol:
License 11:
Aq- I
Cupertino Business
B_L]Siness License 4:
Type of Roof Covering:
n p: PropoSTI:
❑ I I I]i I I-U 1) Root 10 131.lilt-Up root'
U Asphalt sllillujes Ll Asphalt Shingles
Wood Slinkus 0 wood Shakes
,j Wood Shim, .�1� D Wood Ylill&ICS
D (WICI Ll OtIm (SI)CCify)
of QXIS[lll(l CMCIIII.-IS ❑ Plovicic I.C.B.O. Report Y
aj, I,) he Rclllnv�d Provide tyligir. Installation Spccs.
__lve Read- Understand and Will Comply With CLII)CI-tillOIS TC,11' 0ffPoliCy:
W) DC!sCi Ptioll:
Commercial ❑
fire Z_.()llcYes El No ❑ Confirmed With Planning Dept. if
there are any restrictions: 0
estrictionS:
Cost of Ploject: 1)'PC of Construction: OCCUIN-111CY "I'OLIP:
-CDC) C y
Fee ID Fee Description Fee Group
BPFRMPLI RIC]o Permit Fees
13LJII-DINCI
13 ENERGY Energy BUILDING
BSj7jSi\/llCRE Seismic Fee Res BUILDING
------— BSElSlv!lT5m Seismic Commercial BUILDING
BPLANCH117 Plan Check Fee BUILDING
BUSLIC Business License BUILDING