00110042 CITY OF CUPERTINO ,�,,, ,I;. ,
BUILDING DIVISION
'PERMIT- CONTRACTOR<INFORMATi&.F 1
, i�`t�s:DERBYSHIRE 'DR .
BUIIDINC1n SOUTH HAY -REF :+ . H ' Mn'e.
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OWNER'S NA
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E ...RLISSELt � 461, PERRYMONf APPI.ICA'i 0 r rl�" C
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NI.: �[t,�B1 �L79��g 11 _ SANITARY NO. CONTROL NO.
OO ARCHIFECI➢ENGINEER; - BUILDING PERMIT INFO
BLDG fLEcf:, PLUMB EC
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LICENSED
ICL COCPOR 5 DCLARAION Job DBSCflpt1011
I therebyora I.n licensedun pcnsof 9nrmmens'ngOYta wdnstcTian7a0)nIu' . e3annaE c, e....
it,
Codd,n,dnrlsf .a '
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FLIRNACF
isinralllirrreul Cfltta.
—Cw6 License Chisi
h 'Celp
A ,DECLARATIONunder AI I %bdlbru,dspuM1lc mrmd s Is.
OWNER-BUILDER DECLARATION
i'.
nseJ lholessinnvl
11`—�'n• " in bmeny.(Sec a nl 1 ani exengrl Item the Professions
C s'License Law ria the -
C?a whichifa mama. erni,1 ]11365.d,.)it,sunder.deal
Ct ar Anycityor county
x, et which II^i asaIknnio raarn,theLalar,impasse,h parrish,or repair nnysruaum _
L 3 let i I I n, .n Lip III r I p 'l l t l signed L (C lfmc n., -
Ina n 1 d i I I d p : n1 i. I t 1 1 lCbnpaf) Sq. Ff. Floor Area 1 a�A
(comnwu"ng whh SCcdno Tat ad t e Kek a t the.11t,M orni Pmfcsdmm Cade)
or that he is exempt Iherdnnn end the oasis fur @e allege)exwnption.Any violation
of Sermon 1113 LS by nny applicmn 6}u pemrit sul!jegsthe applicam mucivil penally
Lor oat mart d,an rvf hlrtdren dinars fg5nn). . . A �1,'Nut�tw—A. 00 Occupancy Type
°1,as awneroflhe pmpeny,or my,employees with wages as their sole compensation, ,
11 d tl rk,am to ^ wa.C.ratintended e a d Line,.. 1 (sec.nua .,t51 — ROUC�CgfTIketU11ISfTddGbns
III Ie f.x :ild i C I e -:1 1 eI pply tort ?;
nu t r f p perry employees,ld In J h I M1 nk ol e se11 -
nl ghlf mp Jdthl h improvements law year torat - ROUGH hIECHANTCRL
sureffined f .tale.If,h:wuilde the huav r6 lmi ni nem : I ll, one year of i�'~
tninpmdan,are awnfnndmer wlu Lome the nmdmr nrpmving lent nt dln not baud rr 304., ROUGH ELE'CTRICAI_ r
improve far yurposC or side.). -
505 — FTNAI_ ELECTRICAL
❑1,as owner of the progeny,inn Cxclusivcly nmvacting with licensed amtmhars to
croslmm the prajcti(Set.7( ,Bngqlness and Prnaxslam Cade:) Ihe Cammmar's ,'--,107 F T NAL PLUMBING
Lirense Law daex m apply an owner of pmpeny who builds rn itnprnves Ibercon,
Lord who commit r tie pr) Is with a amtmmm s)licensed par,....m he 508 — F T NAI. MECHAN T CRI_
.Commamrs Lac La -
❑larrev der +- I&P C for 0a,wasn't
me /r S p,I /
nes Wf) 'S COMPENSATION 1 .0 dRA ION '
t '
I lumelfty aft r t aide,p nilly f p ry Lane Lot the alboveir,derdenin Loa.
❑ Ibase and 'llCnl t fC n' I - I If tankers
CathI' s p vl d I by S fi f 3700 Il, I1 Coda, far, the
m Lo - ,
1xtl c Ill, w A fe, l, 1 N':1x t J. '
❑1 hisove Lord ilinnuituldn W A r.Ccaft,abiewdout Insurance, meq ImJ by Section O
.371111 ad the I l, Cs l I p f f 11 o rk for h 1 Il- pe til is '
Ins d My^W rkers pens t Ilnsur c rcr and Pid y number arc:
Car,r T Palw,N !
CCItT F C TR OI EXEMPTION IBO -
' COMPENSKliONINSURANCE -
(TLis section need ant be completed if penailis for one n^nArcd delta, .
(SUM)or lose.) -• '
1 cenifr that Lot the perfonrm et,of the xm),fur which This p.it is issued,I
shall not employ any person in any manner so as in became subject us the Workers'
Catnpensmit Ls-1 Celifnmia.Dula
Applicant - ..
you
NOTICE TO APPLICANT.If.after making this Cenilicme of 17 ix
you sbnuld
become subjm m the W'orsets,Campenswian Previsions of the IaMr Cmle, must
z 0 bmhwith r..... willssuch pmvisinn.c or tris paresis,hull MJcctned rcvukcJ.
E` Y CONST RUCTION LENDING AGENCY
I hereby alTna that theme is a cansuumion lending agency far the performance
W
"The work Rn which Ihia pmmit is issued(Sce.3097,Civ.C.) r
-
Q Lcndm's Nuns ,
Z? Z Lender's Address% -
V 0 I terhy teal l have read this application and sate that dic al ove inlinnmlion is
LL r.rrfm.I agrco Io comply will,IJI it,cold miunly nalamares'aid x,am Incas beadng
V
to,building csmarm,tain.and hereby unarm mpmsematives Loi this city to enter upon
} rW the oho c me rJmwd p pemryf Peet t p P •s.
E.,
Q. (W ) yes ms W➢n fy mulacIplid fleoI,heCtytf Cupmtnn against
w.dG liabilities,tt t Its.ctiov,I If rrt :cs Which alay In any way.)cmetgunsl said }I
V.4 City o h g fah p:.nnl /j
SOUL(' GO
T; AND WILL COMPLY WITH`AyL Nf POINT Issued by:1T0 e. Y4 w7J/yyCL� C�/Dilte
Sign. m dAPplicanVGn ban^r DI C// f
Re roofs
HAY.ARDDUS MATERIALS DISCLOSURE _
lYllthe a iplinnn or future huildingoccupans srorecr he 11,hvzardans mmeriulType Of Roof' -
usMlineJbytheCupunir Mir fipal CrnlC.Chapmr 9.12,Lond IhC Health and Safety
Cede,Scefin.255321Lo)] - .
All roofs shall be inspected prior to any roofing material being installed'
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Will dm"Laieltmnrfltmrennildinarx'cuPaulUse Lipmetll^rdmroa,,wnith If a roof is installed without first obtaining an inspectioti„I agree to remove
emit hazardous air cunmminanls us defia by the Ray Area Air Quality Management
District, all new materials for inspection. Applicant understands and will comply with'-
all non-point source regulations.
1/fJ,.)th
e hazardous maimiuls rcquimincnts under Chapter 6,95 of the "
Californiufny Cale tm s25505.25533 and 2553.1.1 understand thatit"the built currend hqv /tenon,that it is my responsibility to nntifythcLot
enpametn a hi' �I n ba met prior In Lcsutmcc d v Cv tilicomof
Occup. Signature of Applicant Date0)JIgam - [)air .y All roof coverings to;be Class `B" or better
OFFICE -.