06050129 CITY OF CUPERTINO -
BUILC3NG DIVISION PERMIT �C*ONRACTORINF�.,�RM_AT I
BUILDING ADDRESS: MAX BCKELMtN PERMIT NO. 06050129
5825 BOLLINGER RD
OWNER'S NAME: PERMIT LSSUE DATE
MAX BOKELMAN
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER BUILDWG PERMRINro
BLDG ELECT PLUMB MECH
±o� LICENSED CON FIACID0.s DECLARATION Job Description
i 1 tr by.fBm dw 1 rm lt,o- endo pmvidotu aChupv+9(c«etrcrcin{
th Scctbn 7OlD)af DivisbnJ.Nc Butitais and Prof mCodc.ad my lkcnsu
+'� brwuamemael REMOVE & REPLACE ASPHALT SHINGLE SYSTEM. EXISTI
L'C� - DECK TO REMAIN CLASS A
ARCH DELAc ON BILL HAMILTON ROOFING PAID FOR BL 5/16/06
`` Ivrikmand tm PWu tlWlMwednpublirccmdt
:�u
.p Lwrn dPmfudoml
OWNER-BUILDER DECLARATION
1 hereby.flim Nal I.m etampt rr«u tOC Canv.ctora IJemtc Law for the
.°° f Ab int roan.(S Cdon IUJ IS.Bud.and Pmframn Code:Any CRY«cattery
129 whkb top...permit m c«umacl ellerhnpmve,dcmolWi.«toW xY 4nsmamICM
-i j, prior unto luttitrm Wurcq.tru ftApalaot rmwch permit to Eka d{ttcd—.1S Valuation
< the hculkcntcd purmantm the P^`gdo^+.We CwunnerY lJmttc lar(Chaaa9
(oommcncie{wvh smion7ODD)aDiWtion 3 a Nr Butlnm um Pmfenitm Codc)« $67000
ithe k u coma omdoou and the b.dt f«the J4 nd etottalm.MY vin"Of —ZVI
ScNoo M31.5 by my appllatt t«a prmtit wbjtw the.pplicmt In a civil peony a Occupancy Type
o«CO.tine five huodred Cbl ISM
❑I.nurar of ttie awrmy,«my ervpbyea Ntn ra{mndetr Ade compenmlo.,
ill do the work oR,,0 awcbve n not inuMd«afford faruk(Sec.7 .Buanm a Iced Inspections
utd PmfeW.Code The Conrntaes I i--rev dam not"ply m+n o of P
aoanYrbn Wito,err lmpott.themo'tta Who domau:h wvkhiwwf«thmaeh hu
twoemplomao^ thatsuchimpmvemenu.rtsuntln ud «aQertdfmnle-B.
brew.U no,,O lo[«hnaovpno t.a mid Winder sue rein.amara®.the =of
buiWo wlB E.ve tie Minden dpmvint tWtkdid.«bWW«impact«poryo¢af .
"IC-).
I.n awter of me prM.M.w mclwlvelY contrrtln[rich li¢n+ed canv.am m
corknmct tltr Mica(Sec 7014,Bminen and Pofmd«u Cade)The Cooinnoh Li-
ecme doon oat.Ppty m m—of aoPOnY wb build"-intp t tbetmo,and
rim mntrsts[«svcL projects riih.can r(t)B d amnam In ft Comnemh '
Licence
❑lammwavMm See ,B&PCf«thi+re ,,n
0. Du
WORKERS COMPENSATION DECLARATION
I booby a(fw uodm ana4Y of perjury me a the(dlorin{(Ind-t liOnOC
tJ1mrtandwifledema.Catl3m dCannmmCod,.14rcr«Workda Caaft
atom u hilt In Rpt by S'Kbm 1700.me Lab«Code f«We perfarm.rt¢.the
wort f«which thin pump it issmd.
1 haver oWoWn Waftet Compensation Imwuwe,u Inquired by Scrtim .
37M a dtc lab«Code,f«dte Perfomura Of the cork for which thl+Permit u Imed.
My wortefs manna. rtim and Pnlcy nu Ier:^. .
Gmic' "L"I- Polity N.-
OF
o OF EXEMPTION PROM ORY(
COMPENSATION INSURANCE r
(TTI xalm ottd a«be carvpkzd Uthe porton 4 f«me hmtred do0an(SLID)
or Ica)
1 euufy tbat M the paf..n¢of We rack f«whkh th t Ph M Luue0.l"I not
vuPioy•y arson in any mmner to u to bmmte wbject On th Woftd Compermnart .
UJ aCdifomie Duc
AniO
NOTICE TO APPLICANT:If.ver m.kin{Nis Cenlfrote of Eicmpum-ym dsauld
bccmtm a Jea on
the Wor4Ys Comanvtke prorldom of the labs cads,You mutt
,J forthwith mmay v ih ruch provitioro«Nis perm"I on d«trcd to,n c
Z^ CONSTRUCTION LENDING AGENCY
ah IbetebY.11lm the shote at.conamaion k Mt.ffncy for the Perforvtmx of
> the wak for whitlt ibl+perank is tutted(S«.M.civ.C.) .
1 Q (<ndcft Nurc
O z todertAmtm
U0 I courY that I haw rvd this aPpll on totd two thin the Wove inf—fin"in
is.E-' CnnV CL 14=to canPIY with all City.rtd awiry aNin.n¢t and Stec lawn rtluln{m
OU building cons tion,and hemby authonrc mprc bilivcs of Nu city to rnm upon Nc
7'W aM.c mmu.ncd pmpcny forimacuon Pmpsa
(We)aprm to ort,indemnify and teeP harmktt the CtY a Cuarurro•tdmt
E'y IiaMhLk&jodtoenm c tool mIontn,which my in my r Y acme:+t,I=UW City
U InConWq+ Of the runner{Of thin pomlL
^ APPLICANT UNDERSTANDS AND COMPLY WTn(ALL,NON-POINT Issued by: Date J
SwAg REGULATIONS.
5�A 10i Re-roofs
s nuum afA lkarulCC99 vac« D.m
Hyi.RDOUS MATERIALS DISCLOSURE Type of Roof
WAIN .pain t«ruttrt bdldmp occupaetm«c«haomc h_ .,..outcdd
I dcMr92 de cupenloa Murtkial code.CbnpW 9.1;and the H ,Jb Lod sdoly
Code.Seam 25532(.)7All roofs shall be inspected prior to any roofing material being installed.
[]Y.m V./W
Tawe bWldlnt .pm «devlan.Mab
Witt the spa"'"'« anc equiamnt If a roof is installed without firs[obtaining an inspection,I agree to remove
crop hvuGnn air ronumwnu n dcfmcd by Nc Bry Arta AU Od'vy Mm.f-'muck all new materials for inspection.
Diwia7
❑Ya No
]b ,Cndthe mmonws tmr,.hr eouutukr Chmter 695.0e Gilt«-
]Halth&Safny Cadc,Suntan 35505,25533 and 25534.1«d wM thon if the hwdM{
doe W'.Oay have.erYnt.that h E my retpoudblity to natty the Derma a de
hare whkbrr=be mittyyrc.+Catiffcucoro . Signature of Applicant Dale
All roof coverings to be Class"B"or better
r wvm +trnt Dox
Community Development
10300 Tone Avenue
; J. Cupertino CA 95014
Telephone(408)777-3228
11 CITY OF Fax(408)777-3333
*UPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
e06 OSa (Z 9'
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
ignature Date
Please check applicable subcontra ors d m lete the followinginformation:
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
om 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # 2
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 37535016 . 00
DATE ISSUED. . . . . . . : 05/16/2006
RECEIPT # . . . . . . . . . 34419
REFERENCE ID # . . . 06050129
SITE ADDRESS . . . . . : 5825 BOLLINGER RD
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : MAX BOKELMAN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
RECEIVED FROM . . . . : BILL HAMILTON ROOF
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : MAX BOKELMAN
ADDRESS . . . . . . :. . . :
CITY/STATE/ZIP . . . : ,
TELEPHONE . . . . . . . . :
*EE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
----- - --- ---- ---------- ---------- --- ----------
BPERMFEE VALUATION 67 , 000 . 00 650 . 16 0 . 00 650 . 16 0 . 00
BSEISMICOM VALUATION 67 , 000 . 00 14 . 07 0 . 00 14 . 07 0 . 00
BUSLIC FLAT RATE 1 . 00 105 . 00 0 . 00 105 . 00 0 . 00
TOTAL PERMIT 769 . 23 0 . 00 769 . 23 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 769 . 23 7015
TOTAL RECEIPT 769 . 23
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
•
a005oaq
CITY OF CUPERTINO
d ' REROOF
city Of
• CUPEkTINO PERMIT APPLICATION FORM
APN# 35_D I � Date:
Building Address:
Owner's Name: Phone##:
108 -
Contractor: _ Licens #:
Contact: / Cupertino Business License#:
G Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
Asphalt Shingles Asphalt Shingles
Wood Shakes ❑ Wood Shakes
X
❑ 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:
Job Description:
Residential ❑ Commekial
Fire Zone: Yes ❑ No F Confirmed with Planning apt. if
there are any restrictions: LJ
Cost of Pro'ect: 60 Type of truction: Occupancy group:
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
•