05100212 (2) CITY OF CUPERTINO Q�z,gsF
BUILDING DIVISION PET CONT�f(;<I�I"^��Tlll]w
BUILDING ADDRESS: DRAEGER CONSTRUCTION INC PERMlIN0.05100212
10465 1•
OWNER'S NAME: PERMIT ISSUE DATE
PACIFIC STATES MANAGEMENT 605 COMMERCIAL ST 10/27/200S
E: SANITARY NO, CONTROL NO.
(408) 536-0420
ARCHITEMENGINEER: BUILDING PERMIT INFO
BO EO PLO NECH
LICENSED CONTRACTORS DECLARATION - Job Description
I hereby affirm UW w 1 Iieeoa d under pmvid«u of CMper 9(commencing
with Section 70OW or Division 3 ofine Budrrcsi and Professions Code.atnd my licem u
+� mmutmeeandeffen `3q REMOVE (E) ROOF-INSTALL 40 YR COMP
j'z Licenm lAc,a
Dam swDanl«cmr_ a SHINGLES 5 YR PLY CAPSHEET
ARCHITECTS DECLARATION
M
I understood my plans shall W used as public records
2�V
yc Licensed Prommumal
OWNER-BUILDERcamp DECLARATION
i I hereby M.that 1 1. ewmpt from me CoaVamCc :my c taw for the
0 o following maw n.(Section 7071.5,Business and Pm.de om Calc:My city or county
5$ which requires.permit r rnres me alcor,hnpmsu demolish,sire sig hay statement
N prior m its issuance.siha requires Em epplianf far Conumch ewe's iccom Law
(Cha mem
< that he is licensed pursuant m Nc provisions of me Conlsan«S Licemn IAw(Chapar 9 Sq.Ft. Floor Area Valn$tbs 0 0 0
E 51 (comommin{with Section 70D0)of Division 3 o m ,•
a BualMand Professions Code)or
that he is emmpl theefmmad she bins Her the alleged eaamisdou My vlolmiun,f
Sermon 7031.5 by any applicant for a permit subjects she applicant to a Civil Penalty of APN Number Occupancy Type
ret mom Jun Rve hundred della,(f501). 32652075 . 0 0
❑1'.ownerarEe property,ar My employees wish"Run As Emir haleeomp ruatidn,
will do the work andthe wucto.boot mended or offered fanale(Sm.7044,Business Required Inspections
and Professions Cade The Conumem,'s License law does ant apply b an owner,of q p .
pmpeny who builds or Improvesch im nand who annauehwoek himsel redlhmu{hhis
awnemployees..metbuipmMded pttm,e impmwmwitarchat year
ded ofomonetw.f«aal,r.
Wildehoummr
she rnafting arden owmwbaid e did at leu or mmpktion.theAnswer.of
hailder WB haw Nn burden or pmvm{that he did at mire m impmw f«purpose of
ssleJ.
❑1.u owner of she property,ern Business
eomracting with Banned wmrwwn m
construct As Em prefect(properly,Businm and cormasioes Code:)TM Comncmrr so '
came Law docs act apply At an sumer of propenyvin,builds or impmw themon,and,
whoconlracu for inch projects with a eonuecmr(s)licensed purausnt m me Contractors
Lkemelaw. O
❑I an eampt under See .B l P C for this roawa
weer
Data V
WORKERS CGMPENSAnON DECLARATION
I herby of rso under i mally of perjury one of she following declatatiow
❑1 ham and will maintain a CerWkam or Convent to wlf4mare fm Workers Compen-
cam.u provided for by Sncdon 3700 of Jus labor Cade,for me perfonnume,or she ,
wart for which this permit is Issued.
❑1 haw And will maintain Workers Compensation Imurace,As required by Section
3'300 of one labor Code,for the penamnance offt wok for which this pari,b West.My Workspra,Com�pasado_n lnmrwm oniv and Pollry numW
Carrier: 7a.l.Gl OCYff US` Pollry Na.:
CERTIPICATE OF EKEMPIION FROM WORKERS'
COMPENSATION INSURANCE
India suction need wthecompleted if the Permit is f«enehummeddo0aa(5100)
Or Inca)
I eertify that in me Performance of the work for which this Permit Is bound,I shall out
employ any petmn In any menacrw as In became subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,aner making this Cenincam of Exemption.you should
become subject In the Worker's Compensation previsions or Jo labor Code,you mus '
.,O foMwith comply with such provisions or this permit Nall he deemed mwked.
z` CONSTRUCTION LENDING AGENCY
[^ Thereby affirm that mem is a construction lending agency for the performane,of
C, me wart for which this permit is issued(Sec.3097,CI,.C.)
�W Lenders Name
M z Landers Address
U Q I ttnifY that I haw mad this applicadon and mm that the above information At
ty
V conett 1 agree m comply with sit city and county andinmuss and mm Iowa miming m
Q building cones«tion.had hereby wNmim representatives of this city mem«upnn the
t21 aMwmentro«d Ompeny fm impaction purposes.
LL (lVe)agrte m raw,indemnify aha keep harmless the City of Cupertino against
v.n rA IlabllitiesjudgmenWeow and expenses which may In any way Accrue,All said City
U zIn consequence of the Stunting of this permit.
APPLICANT UND ANDS A WILL COMPLY WITH ALL NON-POINT Issued by: Date 6 �2 -2-p< --
S REGULA O S.
n f0121kT Re-roofs "—�
Si{name ofAppli IA7AonRD0 Due
RDOUS MATERIALS DISCLOSURE Type of Roof
Will Jus applicant or ruu {«wpata«e m hander hauNoa mammal
As defined by the Cupertino Municipal
Code.Chapter 9.12,had the Health had Safety '
ode,Buchan 25532(3)? All roofs shall be inspected prior to any roofing material being installed.
[I Y. �No
Will the aPPliant m comm Wilding aaupant aha equlprnem ar deN¢a which If a roof is installed without first obtaining an inspection,I agree to remove
omit haysmom air metsminsnts As defircd by she Bay Ams Air Quality Managemem all new materials for inspection.
DisrnnT
❑Yes [ o
I have mad the hasardous materials requirements underChapwr6.93 ofthe Califar.
nix Hcal kSafcty Cad,Sections 25505.25533 and25534.1 undcommi matifmc building
does no,currently hese a hal Naz it 4 Cteresponsibility m notify she om upmt Jus
roqu which ec rprior u a f.Certifk..mafaw Signature of Applicant Date
0 a} All roof coverings to be Class"B"or better
Owner or mthodasd m Dam'
Community Development
10300 Torre Avenue
'Its Cupertino A 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
gkPEI�TIN0
Building Department
JOB ADDRESS: PERMIT#
OWNER'S NAME: S , PHONE # -S36-6 Q
GENERAL CONTRACTOR FAX # - S 3 -D .)�
I am not using any subcontractors: /
St tore 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
Owner/Contractor Signature Date
CITY OF CUPERTINO
2� 1 of 2 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 32652075.00
DATE ISSUED. . . . . . . : 10/27/2005
RECEIPT #. . . . . . . . . : 31755
REFERENCE ID # . . . : 05100212
SITE ADDRESS . . . . . : 10465/10483 MARY BLD G
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : PACIFIC STATES MANAGEMENT
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
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
__________ _____________ __________ __________ __________ __________ __________
BPERMFEE VALUATION 40, 000.00 453.60 0.00 453.60 0.00
BSEISMICRE VALUATION 40, 000.00 4 .00 0.00 4 .00 0.00
__________ __________ __________ ----------
TOTAL PERMIT 457.60 0.00 457.60 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
PACIFIC
) AGE 02/02
• ACIFIC
ATES
MANAGEMENT COMPANY
2510 Stevens Croak Boulevard
San Jose,CA 95128
.:Fax: (408)885-9125
(408)885-9160
October 26,2005
City of Cupertino
Building Division
Re: Casa de Anza Homeowners Association
Re-roof Project-2005'
To Whom It May Concern:.
This letter is to confirm that Pacific States Management, as a representative of the Casa
do Anza Homeowners Association, has authorized,Uraeger Roofing as the chosen vendor to do
• the .re-roofing project oject for;.the. A.& G bit.'ild I Ing (103151, 1 10317, 10465, 10467, .10469, 10471,
. 10473: 10495, 10*77,10479, 10481 and.10483).
Please feel free to contact our office.ifyou should have any questions or need additional
information. We will be more than happy tolassis.i you.
Sincerely,
Pacificl States Management
Tara Jolley
ocr
7 Z005
TJ sl
Board of Directors
File-
CITY OF CUPERTINO
REROOF
• CUPEKTINO PERMIT APPLICATION FORM
APN # c�b 5 0 -75- Date: as
s�
BuildingAddresIcy o2
Owner' �e• l Phone
Contractor: , � � License
Contact: N Cupertino Bulsiines i se #:
� fog-S3(,:-ouao ul�� ��(��IS
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
❑ Wood Shakes ❑ Wood Shakes
• Wood Shingles ❑ Wood Shingles
Other(Specify) �r�e� 4 Other(Specify)�6
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 Descri 'on:
KEftwe. WSAVA lm� llr&iql 4o c >
Residential Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Det. if
there are any restrictions: LJ
Cost of Project: Type o Construction: Occupancy group:
DIM f
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
•