00020146 `CITY OF CUPERTINO : '• PERMIT NO.
BUILDING DlvtstoN PERMIT CONTRACTOR INFORMA7I „
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BUILDING ADDRESS: - , v -'
" ,''' SANITARY NO. APPLICATION 9UBMITTALDATB
-101,59
. . r:R•s. TIME: -- .. -
Q - •*.. NIC', �CONTROI:N
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ARCHITECT/ENGINEER
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�0 ' LICENSED CONTRACT'OR'S DECLARATION. „ I
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z I hemb alum Hn I'w heme0 ewer nn�dr cn, 9 wmmeva � lob Descn tron �• ,
o z=fi r mo pts ( ng .i P
54 .J...11 w�N Salmon]000)ofprvicion3 ofthe Bui saMPmfwiom Cade BM mYlianee is y) (///•••���`% :*T
in�e4 U UNllf and Rat - - .,„ '. ;-,V. t'VYV �Y1— `•'I � '•' i
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vOFi Dem ConlrarH /�'J�t1 .
ARCNII Is,6'S onblip DECLARATION v
f �,S 1 ndeatand my
pisses shell h u«d u public scads 1+
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m .Liccnsd Penfeuioml
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OWNER BUILDER DECLARg30N
I Inneby affinet WI I one exempt from We ContramoYs Lkens,Lew fa the
5 m fi.1lonsing ream” (Section V31.5.Businots sed Pmfcuierw Cone MY City«cvo ty
6 wNch .Re mrmove,demohsn mpei y"m`n ro Sq. Floor Area- Valuation
pnmm ts1once.Won m]°Ices Ne applicant f«sah pemut N file e signei sutc 1 -
Heth ieh«need pmswnt to OW Pmvmions ofth CoeeecloYLeen«tiw(Chiper9 �•��. '
P,.amcsWmg wimsecdea]aooi of Diaeien3efHe Bnrineeivd Pmrensau cade)a - - APN Number O . .7 e
But, -
" l he is exempt Ihaeft ba
lmm W it far He slleW geiemphen"Any vi°Imm�a eeuP Y EYP
Section 70315 by my Bpphcavt fa a pemul subjects d'e apPlwnl to v Civil penalty d - �3 r®� I '
r' rose athan five hurtlrcd Baa
oll ($500).
o I,mowo rafHepop ny.amr ^ploy«.WiHwagnMHeir oh comp au nh; 'Required Inspections'
will dothewak aMe:noC°e ister's eodW«dfaedfa•ele(Sytoan unu A .
and Pvty s na Cade:'nle Contmesen Liame Lew dosnatt w apply le if Pear d
+P�^Y who builds aim otj Hereon,and ns doev such Wmk him«er o through t }
Itis own employax.pmvidW 0w such impmwmenu no va inmdded a oRead for ', � •
sale howew:r Use duM gmtmofv vingu tl nlun WiWwfc°mPlfmn -
4Ndda dl have dw burden fpmvm6 Wth dd nm baW aimpmve fm pm [[�s� tt���IL ttfL •pper�
tf��0NAL1aED .. ..
1'u owner of the mvpesty jus very c°nmanng WM IuemW cmrraron H
IHe pmjall ]014 Bu roeeeaM RofvrialU Cede')The CainW:l°fL 1
«no"Wclnes. Wan
won of pmperry wh bmldsaimpmv«dweo,aM f'�
WMantren w ja��°iUaamncta(s)hamd putuentmth Cenu,Ciot• FEB '1.1"L -
Littnw
'slam eoW
no. - -.B&PC nut
i
Dwrcs •- Date'• :'' BUILDI_I CaLary'.,
' ORKFE'S SATION DECLARATION - n
IheabY affirm rods P'wlry of pajmy aW of the fdlowine daWetiom,
❑IIIeK B11d W111 mYn01nef.el0(<ate efeaeLTlb/GR-IWY f«WOrkefBCallpen )
•arwn,as pmnded fer bySemon 31(10 of de Leber Cede,fm Oe perfoniavice f He `
moat fa WNch this peimll is inuN.
❑1 have W willwinuin Wnrkcl•ComPaeaion Imumae.u agnued by Sa:litin ,.':1 .v+ )
`3]OpdHe labs Code,falhperfomiaaedfh wakfriwhich Hu permi,uiemed.
My Waters Coolpemaation lsaumae carriaWPolicy numM aie:.. 1.. .. - .'
.j (Carrier. : - ,Policy No.: f
C"rF C;k OF FXEMPr10N FROM WORIOIRS'
COMPENSATION INSURANCE
flbiaacfian o«dnethamPleRddHepmNlufaaelhes,son Bees($100) ` w •, •�,
L mlify a s t in 0e pesfamanx often wak for which But panel ei issued,l shall
,notemploy.ny pecten in any mep«r In as to Baume subject In We Wakm'Cumpen . . '
rasion LewedCehfomia Dae
APaiaa
NOTICE TO API'(]CANT.If.affa mvkmg Hi•Cadficae of Rx..Pd.,Yw should
becomc mbycl tothe Workd.Cenlpenatiaonon•i°md'He Leber Cede.You
fathwiH eaoply With such pmviswm ne His Permit shell be damd
,Z CONMUCfION LENDING AGENCY wJr• 1. . " ' •' .
O .• 'l hereby edlions Hae ie.ctmlmcum lcndirg aBmcl,forth Paf,mw-d •'•
Z mor Oe wmkfm which His pnmil uistud lScc 3119].Civ.C.) ,
- a ams 'L<vdrfa Neve -. . �'f. ' _.. •' .,. ,
lindlet Addmss'
°+ 0, Q 'I cenify Har 1 hsve rad Hie app(. an I e Lha len ibove mos enlsslim is -
l>, cwmetlepttmranplr wiH.11 dy y d- nae6Wareladngm
UO bonding cenwrvcliw,mdhaebYm thisdry memei uP®the .. . . ..,
W H .b•p.ve-1Cd fo imPaliml vas City(Wo) to sees,rMnrmdY ab keep h,mkss NeC •:��j �f
C°P«ow+V�rvt ,. ,:, ^ • :�v'OJ t:3. F.1 L
0 G -4eNliuea.p'd6n'aite;muaodexpmuu WlucA rmyinmY w.ramueegvmt aid CrtY - -. e,[
APPLICANT
NDPRS ANDS H"v pemul.
W APP((CANT UNDERSTANDS AND WILL COMPLY WI FIT All NON POINT, -
V � SOURCE RBGULATIONg.
SignaooedAppliaamfCnmsla' Das ,f/Jr f ' - •.
FIATARDOUS NA3TRIAI4DISCLOSURE 1 ti70
Will Heapaicw«fom«arJdingaanp.nt.mm�orheadinhneriaara mntaial :Re-roofs • .. _ ,. , .
_ •., "T ss hfi bY..dc Cip bw Mummpd Cede.Ch*w 9.12,a ft HeaU�Sderyt• •. ' .
. . cads,SwistsZ532(.) <Type of Roof,' ''. -
Will the,ppliuev no - .Igo,, t e e�renl are"�i�r,d,r�; -All roofs shall be inspected prior to,any roofing material being'
eethavaen•alrceelane by Ron Bay installed. If'aroof,isulstalled.withoutfirst obtaining an,inspection
Dienes? ` I agree to remove all new matehals;for inspection. Applicant
❑Ya
M emW IIYa.b mamOOaamtiv ClwL 699 afh Gb understands and'will",conipN,with all•lion point source regulations..
'ramie
Sesofa;Satioo•25NL5,25531 evil z55341uodvnmd Has frena '
drilling ylentoa lhsnnmy mspwsuM1'LtY sten, eoauPsi
dHe da
Signature of Appbcant Date
v Dw1Y3 1, - DaIC
All roof coverings to be Class 'B"or better .
'OFFICE