00110048' CITY OF CUPERTINO . ;• .. , . , -
'BUILDING
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CONTRACTOR INF/Q�RMATTTON
DIVISION PERMIT -
BUILDING 'A f,lVYG / DOLL I'NGER RD
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ERMIT N0,7101 �QIny4s .
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APPLICATIO OH '
J" �1. �T�/,2000
f THOMAS : V AND JEANN I
E M -'/ydix
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ONE:'
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SANII'ARYNO.. CONTROL NO.
ARCH] '1'EC' ('/ENGINEER:
BUILDING PER MIT INFO
ELECT PLUMB MECH
IICENSEDCONIRACIORSDICIARATION
1 Job DesGrl t10
P
ih hyIE vh11 licensed 1 p fChapter 90anna y
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wlthSection '1000)ofD nmol lheBu e, and Pul.. or, Civil at liceme
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DEMO.'
itinfd'resedelle gp �D .
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Liters,CI . _� L N JUZZJ V '.
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Dill Contractor
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/��j/. ii AAlkCHI rECr'S DECLARATION
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j tnacnwnd n( ty Pat _e 11 hclnJas public at
iLicensed PI:.
I .I]LR Dt CI ARA -
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I brat
fl that pt f th Connector's L' Law f thefoll'
r,or, ] Buse JPclean one Codeceo city., e my-
6rels,'sa
onIS,
which erner t
1 which requires n permit ro mnxuuet, alto, improve, donnish, or repair any 5lmemre
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is, iexnthe menu
pin 1Lfrca,le signed
Sq. Ft. Floor Area '
InO n licensed p restars to thslhcoperunl
he Contractor,
c t , 1 Ln (Chapter
p '. Cha
Section taj l
(co a n 0
the '. 3 f theB I P f: :Code)
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n enol
n -J 1h '. p10 1 ad he alf, Lie the clapaleval AnYviolationSr
I' ]031 5 by y ppl' t l a p t t hj rs rhe oppl' t I Evil p n.11y
oft I_ Jrces fiveh add llr,($5001
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APN Number
.Occupancy 0
pZ5923027.1310.
._E9 _,X027. 1?10
all
will d 0 k I thet t tintended If J f al (Sc ]f144
ed sale (Sm.
Bu.t. and Profession, CI ThCn t.' flc v'1w It: hot pd, to an
rn.alwhrdoessuchwekltnnsell
- quireg ��❑❑,wins _ -
MD ASSIGNED SNSI?�!-..C, ONS .
orrofpropertyWhhuddsor0apnreeth
11 rough bis evil cmpinyec,. pnnldW Thu such Impnwelnenle are not intended or
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offered for sale, Ih Itewnvaq the huill I, imprevelnent is cold w'Imia one year of
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counplitor, t 1h e b will h' h burden fp- forcingh did tb'IJ or
alp t le
. p I le)
,
❑ 1 n f(he p pert an I IYcentrarlin, ith licensed auntrael 1
crasher, he p once, (S c 7(44 Business one Pbrfic,iCode.) The Contract"",
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L case Law J 1 cpply to an casual- f property 1 builds n pu e. ascona,.
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who contracts f h projects with onmucr(s) license(] pun uani
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all L L
�t ,gtheunod
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l.ne,en �rsre R P t
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owns
„ W(IRKf R S COMPENSATION DECLARATION'
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Ifivisbyallneuraderp,analvel pcptry court doe foll s' bled
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1 have and will hanothin a C li of Couch to : If on ro for Worker's
f Secti
for by Section 3issu 0[ oho Luber Code, for he
caterrundon, a, e
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1_0
pertnrmmnce of Thu work for which this permit is Issued.
ark r
eQIh d illmulnt' W km: Ctmin:'1 I.requiredby s•d on
• 3700 of the Labor Cal , f lottx f.nerve of the work for wlach this peal it I,
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Issued. My Workers Compensation Insurance carrier and Policy nonuser are:
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Carrier, policy No.: -
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CERTIpICAT10N OF EXEMPTION FROM WORKL'RS'-
COMPHNSAI'[ON INSURANCE
(This suction need not he coundbud If lie ,all, is torr c hundred dollars-
6100) or less)
1 eerily hill in the pilloulancrav, of 11 1, 1 hid thisper t e i,sued, I
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hull ply p y non r n to tM1 Workers
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Appl n
NOTICE APPLE ANT ❑all r nm�-I. Icy 11r1E Cern pt nn yen should
hero u a IIii locus Coor,enation provisions of the LabChile, you runs[
forth,1h curtly with such p v nuns e, lin ,can( that be'detailed revoked'
CONSTRUCTION [.ENDING AGENCY
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I heresy vii m that here h n construction lending agency for the performance
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of work for which this penni 's issued (Scr�j119]rCly. C.)
,
Lender', Name-
[.codcr'sAddeess 7/°/rY•C
I candy lhat Ihave d flar, j,dertlionI satic that the above infatuationis
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r t l i"ce t ply with all '1y and County braireprestuld state laws f g
v ,. '
alb Id g :t ctI and h by d p t I' f@ city to relation
the base uncolored ryro,aryl :, tippii
(Wi agree to save, androunifyadkpl less the City fCupertino y'.t
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lasl1 jild,al cost, and c., , 1 h uy ntinY way accar agotea :ad
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City .ounce of thegr fill, of ta'' p raft
NDS AND WILL COMPLY WITH ALL NON -POINT.
k ,
Tci%.p -�/� vAPPLICANT _
REGULATIONS
Issued blti,'e, !•�ih•�7..C/cc•" Dale
.SOURCE
'gnawredr A,hetml)contrnamr - Dale
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the app scam er fntmn b ldar, occupunl more or handle lecternmweti:d
Type of Roof ' - • - -
a, defined by the Cupertino Municipal Code, Chapter 9, 12. and Ise Health and Saltily
-
tide, Section 2553200 , '
Ll Y,,
All roofs shall beinspectedprior to any roofing material being installed.
Wi 1i flutJ applicantrl t b'Idia,occupantumequ'ptt ill J ,wink
If a roof is installed without first obtaining an inspection, ('agree to remove
all h J mol n a h,Ifi, by it,, B.,A... A Qua 1,M agematn
scoria
- all liew materials for inspection. Applicant understands and
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will comply with
all non=point source regulations.
I have,read the hazardous uncork acluiremena under Chapter 6,95 of the
2
Call brain Ilwlth & Safely Code, Sections 25505. 25535 and 25534. 1 undcmmnd that
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![the building also, not currently have a letunt, that it is my responsibility to'hotil'y the
'
occupant f the squ occur, which muss he'out prior ne issuance
Occnpnn
Signature of Applicant -,• Date -
r
All roof coverings to be Class "B" 'or better .
OFFICE
CITY OF CUPERTINO
7Item
1 of 1 BUILDING PERMIT RECEIPT OPERATOR: karenb
COPY # 3
Sec: Twp: Rug: Sub: Blk: Lot:35923027.00
DATE ISSUED.......: 11/09/2000
RECEIPT #.........: 13981
REFERENCE ID # ...: 00110048
SITE ADDRESS .....: 7497 BOLLINGER RD
SUBDIVISION ......:
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: PALMA THOMAS V AND JEANNIE M
ADDRESS ..........:
CITY/STATE/ZIP ...: CAMPBELL CA, 95008
RECEIVED FROM ....: JB
CONTRACTOR .......: LIC #
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP .... ,
TELEPHONE ........:
FEE ID UNIT
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BPERMFEE VALUATION
P&HK PERMIT FEE
4ICRE VALUATION
TOTAL PERMIT
METHOD OF PAYMENT
-----------------
CHECK
TOTAL RECEIPT
QUANTITY
AMOUNT
PD -TO -DT
THIS REC
NEW SAL
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7,000.00
----------
127.00
----------
0.00
----------
129.00
----------
0.00
1.00
62.25
0.00
62.25
0.00
7,000.00
0.70
0.00
0.70
0.00
189.95
0.00
189.95
0.00
AMOUNT
NUMBER
------------
189.95
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6206
-=�_ae 189.95