05110106 ci,ry ov ajPuitrlN()
BUILDINr DIVISION PERMIT
COY jZXCTOR Mj0RMAT16*'1.,
BUILDING ADQR M- : PITIMITNO.05110106
-I601 S DE ANZA BLVD ff I 50__
-Rs NAMC: PERMIT ISSUE DATE
DOLLINGER PROPERTITES
SANITARY No. CONTROL NO,
ARCHTIECT/ENGRNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
lOp LICENSED CC!,mIAC70R'S DECLARATION Job Description
ZC I hoodby air.that I am licensed under Provisions of Chapter 9(oommencing
0
with Section 7")of Division 3 of the Business and Pinfiessimm Code,and my lira died;
.sead SIGN--NEON SIGN &AL
I
mono fame and officei. (REFER ,REALTY)
,�J, LiceducCluss
Lic.N
❑ Dan—C.dorcuor
ARCHITTI=DECLARATION
I understand my plans shall he cud.Pchfi,re...do
U
Licensed Prafrolatural
03 OWNER-BUILDERDECLARATION
I thereby affirm Nat I am exempt to..the Cchouracon's License Law par he I�S_
IE
0 C following mason.(Section 7031.5,Business and Professions Code:Any city or county
2 6840
V which muchick a Permit w....ark..alcor, marrove,demolish,.1 or.il.1 vrudwo,
1
I / ;,� / - $3000
C '1 —
-ie
prior in its issuance,also mraims the applicant for such permit do rim a signed Salesman 11
Elm that he is licensed pubandent to the Forivisions of like Canadian's License Law(Chapter 9 Sq. Ft. Floor Area ;,f Valuation
,F2 (commencing who Section 7")of Division 3 or the B andeas and Professional Code)or
thift he Is exempt linerboard and thee basis for an,alleged exemption.Any violation of
Section 7031.5 by any applicant for a pandift subjects the applicant to 3 civil penalty Of \qccupancy Type
not mom dian fivo hundred dollars(SSW).
0 1,as owner of the pacuporty,or my employees with wages as their able comptanation.
will do We work and the,nuumbin,I,but intended or offered harkare(See.7044.Business,
and Profession,Cala The Commatim's License Law does not apply to in owner or Required Inspections
gumorky who builds ler improves thereon,and who dos such warklainakelf.,through his
awn employees,provided Nut such improvements we not intended proffered for sale.It.
however,am building or improvement I.sold within one year mfe.bar,dourba,the owned
builder will have(lie burden of Pat dint he did not Wild or improve far purpose of
d:al awas,Of ind ritually,ind ex.1hadiv.1y candectir,adan,licensed commound,10
ball the'fayeeL(irm.70a,L Business and professions Cable:)The Cmdreaduar's Li.
'no
;.Law don not apply to an owner or knomeny who Wilds or bunparkner daemon,and,
whoc
ho rblu-matarbibuils,projecia,vil cian-bi)deed Farawknot come Colonnades
License License W,
r I= c. .1,&P C for kids draddrat
thae jLOLo_5
e an 4P ",
CB'S COMPENSATION DECLARATION
I hereby affirm under rowdy of aaddC,care of the following
I las we and will maintain a Ciardficate,of Consent to selfAndure for Worludwa Camped.
ration,as provided for by Section 37W of the Labor Code,for me perfournabooke,of und,
warc far which bis nermi,is issued.
f7 I have sad will maintain Worker's Compensation Indandance,as required by Section
37W or he Lather Code far to befferouldsc of the walk far which this pe.it A issued.
My Worker's Compensation Insurance carrier and Poll,ranatte,ase:
Carrier. Policy No.:
CERTIFICATE Or EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This union need non t,ccompleted Ir1lis permit nfor enc humbloculdollen($100)
tar lesa9
I kabrUN did in the pert of the work For whictk41d9-f,_rm_7l i713yed.I added no,
se
durabto an' rson try law scam cil alvit3win,mTc..Nbkau.O
Laws a.......
pprein, 1%;g,kw,�
NOTICE T&`APPUCAN7r.If,aftar making this Composes Or Exemption you lJoul:
become Subject 10 the Wrolict'S Coldrobacenike provisions of the Ichor Cade,you must
z raoMwith comply with each prevoind,or nor permit Ideall M destaboad rovalud.
z 0
P Na4 1 troke by am,on CONSTRUCTION LENDING AGENCY
5� am work(or which
dri them is,candoundeturbirk lending agency for like performance of
Cd
a a'amin issued(So..3W7.Civ.C.)
a, Lender's Namc
Le.den Add.
U 0 1 coldif,me,I have lead in,application and vento 1hal the above Information is
LL concii.I agree to comply with all city and county inundation and auto laws relating 10
building construction.and hereby ationavite representatives of this city to crime uponffic
above-mentioned praperty for inspection parfroses,
W
0.
(We) to save indemnify ad keepbrharmlessss the City.1 Cimunina against
(WI ulthirtims,jtAgrodues.,exies andia,man which may in anyway act. ,i.1 said City
U z _'a' 'granting
ri�bng O"b"'
APPLICANT
ER TANDS ILL COMPLY ITN ALL NON-POINT
SOURCE
CA by: Date 1(,,w� JC -0dss-
R TIO, sued
O
Li ate
(11P Re-roofs
D
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appileart or fluatem building ormuladan,store or handle houdsmous material
defined by[le,Cupertino Municipal Code.Chapter 9.12,and flive,Health and Safety
Section 25532(e)? All roofs shall be inspected prior to any roofing material being installed.
0yes 9�- if a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or relare building Occupant use equipment or devices which
.mit ha,,ambis air c.mckarindents as deflood by are Gal,Ann Ail Quality Management all new materials for inspection.
Daniel'
n Yes
I have rc.saj the borant a..als doundrocri Chkkpbd,6.95.f,WC.Iirm.
riaHe Sm.- 5 53 534. understand thatifthe,Wilding
bod, y
a clud
I' me , ,LmYRN
can as car =`a tenant. I my .in nowj be occupant
rue,
T andarm "I S,
q,uncom ich had N me i handed. cidbEck. Signature of Applicant Date
Oor siamnoall aged,/4 I All roof coverings to be Class"B"or better
wner