01010125CITY OF CUPERTINO �
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CONTRACTOR INFORMATION;:
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nun.mNdDtvlslov PERMIT:,;
BUILDING ADDRESS.PERMI
R1. 345 f r -u TA L�I_�I
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OWNER'SNAME:" 5
CUTLER GRIEC31RY I
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AM 1 MAI" ,' a u: o'; n4
APPLICATION SUB DATE ..
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SANITARY NO: CONTROL NO..
' ARCHITECT/ENGINEER: - ),1.,
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BUILDING PERMIT INFO '
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PLUMN..,
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LICENSED CONTRAC TORS DECI ARNITON
lob Desorl tion '
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p : IChapmr9 homme g
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IthS tion761101 fD 3 fIhrpm and Pn rest ois Cade, d ty1'
i isimfull : e -� —
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I;CI,(ttJr"/aillII7Vr'ExIST11,I; I -AY R.(IF wC1IJn SM -
Dat ca "a or _
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TNST6bJ_ HEN, .l./?" CT7X, :3C•7t3 I L7._T Alln 1RJriAI..
' S ECLARA
I`Fdersandny plus shall be Lived colds -
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livens -ed rmrensn,nm
- OW NF.RIilJI1.IlER DECLARATION
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1 hereby airport thin I ren exempt fi m he Correction, Lleene, Lew for me
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following person. (Section 7031.5, Buenas atm Pmfeewmn.. Code: Any any m enemy
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a which requires a
,alsdi papareh 1 d tin -P r:aamnre
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'do,t t reynrestne applicant fo o such pertn6 tale a signed statement
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- Sq. Ft. Floor Area
Valuation
ohalheisheareedph..ndid to the powsitxof the Commanders License Law (Chapter v
he emanates with Section 7xml of Division 3 of the Business and Pmfes.ious Cade)
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or that lie Is exempt the iefntm and the hnsis for the alleged exemption Any violation
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of Smtion 703 1 5 try roy appllcent for e pmmit sobject, tic applicnnndu dvil penalty
now,hand -
- APNNumber,
Oc_upancyType
°limits rerofthe proppny,nr(ny enlpinyeeS with wages as their solo cnntpenmtion,
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- $17ta"`:%
Is &I he k W did thedure is not intended or ollared for take (Sec. 7044
'Ila d Pr, r t,l C I,: tin C t t L Ln d pEly In ah
- Required Inspections .
y w i p ply Wn l ld p n h d 1 1 k h'msmf
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orthroughle, awn enllr provided nt: h Iq en t: t 1 tied or
.13057 wf%1l�
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offered for sale. If, however the building or' np ovemm's sold within one year of
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Iorphaian the ownnrh'Id'r will have the harden of proving that held ret hdll hr
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mprove for purpaw'If 'li L _
305 "" FRAITH'":
❑L.aowtier ethe 1 i; contracting mr d eIII" t
3f%I"l' 7:NFi(.IL..A'T'1I71d ..
sly
construct tl p 1 ecp 7044 d t: CW ) ne C t 'I '
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Licensen o,. ,w
t ouch tip Arty n n m m
e p
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_ y.` 60:1. riY.OF' TEM GFT=
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roti I r i proiecU wm eomm,nrcs> licensed p ant aie
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Ce t : I' L ,......
.,' Gk_.) :... 'ly'IJC1P- PLYWOOD hIA1:1....
111 m exempt order Sri. B ;r F C for this reason
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(',C) 3 Fs4a11= TiATT'Ei:hLri
Own Date a
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- WORKER SCOMPENSATION DFC1ARAI[ON
'ye;x�}, "" I\'GGT IISI'1-tF�4lGlk1'JE:)
Ihreby iffifor under penalty of perimycone oft1ef11 'd m
f 17 1 h d will condition a Cartificub, of Consent to scifl-insrefor Worker's
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p : i -d 7
f by Seen 3708 I' theLaborCfile f the
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ra ep
M t o ce fahhk f h hth t
1 1 . d.
If
ntWorker's Compensation Insurance.;�y' IbyS tion
v(and willmaintain
37( he Labor Co thepamana I k whichthis amour is
"wed. MyWorkers Compensation
'mp i rcarrier and Policy nonitherr
Cartier:�Pol yN 0�l'P
.. F -ll—
s CERTIFICATION I IIONRANC WORKP.RS"
a
^ ATION
COMPENSATION INSURANCE �
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IT1 e , n need not he completed f the per n'I la for one hundred dollors
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[$ I11111 er less)
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1 ecopl that'll pci I k f H h the Permit i
shall not a nploy any r
m, ry neither s m Haab Lie wnjeet ro the Workers
e Workd
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raperson
-Comyensotian Laws of Gdifnmin. Onm
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NOTICE TO AI PLICANf It fl ak'n6lh C tf t fL hpt you hold
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Iuume suhject to the N k :C le 1 p of the Labor Code. you most
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fad harm cohnplyw'th SuChp t. Lir the permit shall he deemed evolved.
v CONSTRUCTIONLFNUNGAGENCY
1 rffmt that there Is a mnstmatian lending e. fonhe perfnrmunw
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weektoo
- of work rarwnien thi, partnit is is..ned (see. 3097, civ. c.J
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: Lender'rNnme
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-Lender's Address
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I empytl allnorpordTh: PPI t d late thadII hove eftinamich'.
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correct. I agree In mandy with' R city.and County ordinances and state lalalng
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toblfg construction, and hereby authorize representatives of thiscitymetertpon
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= the nb mwel p p ty r :p hi .....
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(Wed agree to save, -orderrailyaml keep In I : [lie City rC Calvin go na
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Tab lio :, judgment, a -t. and exile uses barmy in any( 'at ewe against said
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Cit onsryucnce of the granting Lif this Inennif.
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P VDE U WI COMPLY WITH ALI NON. DINT
so
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Issued by: Dale
fl R' ems: I
sig at nprhean✓ arI .• Dole
Re -roofs. s;
• ,HAZARDOUS At 10SUR1
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w n t ppf ant 1 t b ho, telluxon bar, lie ImOrdon, huma, td
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Type of Roof - . •
Cdellh Jhy th Cp t M aIC It, CI a 9.12-nodt Heath dSlty,
Code S I' 25532(')
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All be m Q
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w u dapplies,,, r g eapant n. i e
roofs shall Inspected prior to any roofing mial b stall ,
If a roof Is installeii without first obtainm an ins n, a rue to remove
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m'th I t n dbY the Bay Au.A'Q I't haul
ge,
Dia t
g
a tenals for ins ecfion: Applicant
unders sate y�t�I qo 0l�
'ons:
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on- sour ruga JHIV N 1' L�C7 I� I:
d r cn n d.9s or aie
II e a h 1 , t ' 1 y ' - t. Lirl
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tf Hhl &SuftyCd S t : 5505 SSII d255341 t Jtnn
tly have sten Ith ll, bl "the
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Y p tyt
the Lit, huh pr ar m usm of a ort i cam I,0
4,ldua,Jstat
atureof" pplicant .1 Dote
v.
.-All roof coverings to be•Class "B" or better _ '
t e rgem - -, Date
OFFICE
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