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06090114 (2) CITY OF CUPERTINOr BUILDING DIVISION PERMITCUNT==RAC? R, N1*70 E'DRMATIONi., BUILDING ADDRESS: DRA GER CONSTRUCTION INC PER""O.06090114 10381 MARY AVE B E PERMIT OWNER'S NAME: MUG DATE PACIFIC STATES ASSOC SERVI ES605 COMMERCIAL ST 09/15/2006 NE: SANITARY NO. CONTROL NO. (408) 536-0420 ARCHITECT/ENGINEER: BUILDING PERMR INFO BO EO PLUMB MEOCH o0 LICENSED CONTRACTOR'S DECLARATION - Job Description u 1 hereby affirm that I am IlceMed under provisions of Chapter 9(commencing Z with Section 7aM1)of Division 3 ofthe Business and Prebend..Cade,arm my license is Mfullforteand G,7�/a REROOF- UNITS 10381-10411 BLDG: E t122 Llcenan Cl IJeM Dae a Gomanor G attt. TEAR OFF EXISTING, INSTALL 2 LAYERS OF 30LB FEL i~ ARCHnEcrsDECLARATION UNDERLAYMENT, 40 YEAR COMP SHINGLE & BUR, 100SQ i I understand my plana shall N used as public records InU E pp Licensed Professional C5 OWNER-BUILDER DECLARATION NI 1 hereby stiirm that I am exempt from the Conaanorf License law for the .o O following mann.(Section 7131.5.Business and professional Calk:Any city or county S$ which requires a permit to conWuck alas,improve.demolish,or repair any uromme -.L prior m its iuunme.kids requires theapplicant for such permit refile aaignN sutomcm e—p that he is licensed pursuant to 0m provision ofthe Contractor's License Law(Chaper9 Sq.Ft. Floor Area Valuation €3 (commencing with fiction 7000)of Division 3 orthe Burnessand Professions Code)of �'10tIQOp that he is exempt therefrom and the basis for the alleged exemptlaa Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number - Occupancy Type not mom than Ova hundred dollars(5500). Lu owmmra dieproperty.mmyemplayms with wagesu they seta compeuaCan, will do the work.and the strunu,is wtimended maffered for sale(Sec.7644,Budnm Required Inspections and Profesiou Code:The Contrurora Lim=law don set apply to an owner of q P property who builds or improves thercon,and who don such work hhnul f ar through his own employees.provided That such improvements art not uncoated oroRered forals.If. however,the building or Improvement is sold within ON year ofcompb:tion.the cater- fes., $Lys ale.)will have the burden of proving Wt he did set build m improve for purpose of I f�+fl(� ale.). I'f�tr:,+,+,llt//9rgfff!/rri(pf 1llldlflfsh,,t�kwJap�� 1,as owner or the property,am exclusively comruting with licensed comemnun to ceuwn the proven(Sao.70".Business and Profession Cods:) pro Csnou on. cad whoLaw dors sot apply to an wither of t Property who builds or improves Corton,and. wM contracts for such projects with a convanarta)licensed purewnt to the Canvanars Lemma law. .eft 25- 2007 ❑Iameamprundu Sec ,BhPCfar Numason Owner Data WORKERS COMPEN DECLARATION A^ a s. I hereby aRrm under penalty of perjuryOn of the following dnlwiaas: rte/ U\\UJj I have Doulwill maintain•Ces ilmate.t Conserv m alt-insure fm Worked Cempen- ation,u preAtim!for by Station 3700 of Na Labor Cede,for the performance of the wart for which this permit is Issued. ❑1 haw and will maintain Workers Compntsauon htsurana,as acquired by Scedw 3700 of Ce Labor Code,fm the performance of the work for which this permit is Issued. My Workers an Compensation Insurance carrier d Policy number am: C.'rhu: —11l ,{�Si) Policy Na:'7t3-O�t S] ' •CERTIFICAT ftEMMON FROM WORKERS, COMPENSATION INSURANCE This section reed Out becompined if the permit Is form hundred dollars($1001 or Ins) I comfy that in the performance of the work for which Nis permit is issued.l WII not employ any person in any manner an as to become subject to the Wormus'Compensation Laws of California.Dam Applicant NOTICE TO APPLICANT.If,after making this Cenifmcae of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you most .,O foMwith comply with such provisions or this permit shall be deemed revoked. z'� CONSTRUCTION LENDING AGENCY [.r (hereby affirm that them is a rnnswcdnn lending agency for Tse Mrfmmann of (Yi> the work for which this permit is issued(Sm.3097.Civ.C.) Wry A Lendeh Name z Lcndeh Address U 0 1 certify that I have mad this application and state that the above information is If. comet.I agree to comply with all city and county ordinances and state laws misting to 0U building eonuueflon,and hereby awhoHm repretnutiva of this city to enter upon the W above mentioned pn merly for inspection purposes. (We)agree to sive,indemnify and keep harmless the City Of Cumrunu agaiost hFn f0., liabilhinjudgments,costs and expeues which may in any way acneagalastaid City U in consequence of the grunting ofthis permit APPLICANT U DERSTANDS AND WIL 1PLY WITH ALL NON-POINT Issued by: Date SOUR RE IONS, goo O0//�yo 7 Re-roofs Signuum of Applian✓Can'ARDOr goo HALARDOUSMATERIALS pavastDISCLOSURE Type of Roof �--' Will y t applicant m forum building amupatnme m handle health n material u deRneO by the CupuWw Municipal Code.Chapter 9.12,and Che Health and Safety Code.Smile.255324)? All roofs shall be inspected prior to any roofing material being installed. ❑Yrs o WTI the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove - amit hazardous sir contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. Dimict7 ❑yea zxdl I have mad the buanhms mamdats requirements under Limper G95 ort he Califon nu Hnithk Safcty Cade Sccdmu 25505.25533 and 255X.1 umimmand thuirt a building docs not currently haw a tenant,Nu it' my respomihllay to entry me occupant of Tre requlrcmcn sun' n met tc' ac cruricaeoroccup Y. Signature of Applicant Da won W emhariYee sgam 9' a All roof coverings to be Class "B"or better Community Development Cupertino OC 9 014 Telephone(408) 777-3228 CITY OF Fax(408)777-3333 #UPEkTINO Building Department JOB ADDRESS: PERMIT # Io - i 'Zi.-lI � M OWNER'S NAME: Pt PHONE # GENERAL CONTRACTOR:D Coa FAX#VOT- C.--O I am not using any subcontractors: 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 � 9 ,S Owner/Contractor Signature Date CITY OF CUPERTINO em 2 of 3 PERMIT RECEIPT OPERATOR: amyw COPY # 2 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 32652033 . 00 DATE ISSUED. . . . . . . : 09/15/2006 RECEIPT # . . . . . . . . . : 36055 REFERENCE ID # . . . : 06090114 SITE ADDRESS . . . . . : 10381 MARY AVE BLVD E) 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 . 00 878 . 72 0 . 00 • MqD 114 CITY OF CUPERTINO 1 , REROOF CUPERTIN PERMIT APPLICATION FORM �Al'N� y 2-� n Date: n Building Address: !� �j n I Owner's Na e: CJ Pho a #: ORE- q 16 o Contractor: License #: & I-+U ' o C-3 3 Contact: �Cupertino-Bu`sine ss "i -s Type of of Roof Covering: Existing: Pro ❑ pos Built-Up Roof Built-Up roof ❑ Asphalt Shingles ❑ Asphalt Shingles ❑ Wood Shakes ❑ Wood Shakes ❑ Wood Shingles [ ❑/Wood Shingles Q �Other(Specify)��r t][ QI L Other(Specify) 40o romgsh-1 e, Num rofexisting-co-Mrings __7 ❑ Provide I.C.B.O. Repor t �l Twbe liemoved'-Y- ❑ Provide Mfgc Installation Specs. • I Have Read, Understand and Will Comply With Cu ertino's Tear Off Polic Job Description: -,x s o- F=� t Residential Commer al 100 SR -Fite` Yes ❑ No 0��_ Confirmed with Planning D,_e,Pt. if + there are ny restrictions: u Cost of Project: Type of on trruuction: 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 •