04030074 CITY OF CUPERTINOh^ v.'
BUILDING DIVISION PERMITzCONTRACTOR4INFORMATION
r`¢3. :�,=:x t✓. •.:neh;§� t> .. ;.1`k�'1meR.sit,- e
6U ll-DING ADDRESS: PE'" "04030074
MIT NO.O 4 0 3 0 0 7 4
21
O'WNER'S NAME: PERMIT ISSUE DATE
MARK & DANETTTE MAVROUDTS
NE: SANITARY NO. '11ii� CONTROL NO.
ARCHITECT/ENGINEER' BUILDING PERM rr INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LOo LICENSED CONTRACTOR'S DECLARATION Job Description
h S
d C I he by afFrm that I am m
licensed under provisions of Chapter 9 Momentin
U with of Division 3 of Ne Business and Professiom Code.and my license is
infull I as freer. [ ADD 427 SQ. FT.
cd.Ca Lie Dole ala `1 " CONTRA OR: FCI CONSTRUCT N, INa(03/12/04�)
p Dale - tpC -
A HITS S DE AT ONS4anderstand my plans sha)be pcd u rp lic mca cla
o ff Licensed Pndcssim al - X111 / �3 OWNERILDRR DECLARATION1 hereby arfirm thn1amexarnpi•fosal Cont, .,'afLicense Law for ft-following memo.(Section]1131.5,Business and` resssi Any city ar�counlyI
m which requires a Pcmlit m canswct,alcor,impmw.demolish.6rrtPucany.;Bupie
FZ< priarN iia iSLllanCC.aI2U fCQuirCa llM]ppllCanl fol SYCh pCr`nIIWEleaslgneds m nl tr'
Nathislicensed Pursuam to the Provisions3the Camrceen;an Cense lsw(ChaPt 0 S FC! loor Area Valu�rdrA' s
ter$ (commencing with Section 7000)Of Division 3 Close Business and Rofessians Code)or �w� �,y 's' "
that he u exempt ftmfmm and the basis for the alleged exempdon.Any violation Cf
Section 7031.5 by any applicant for a permit subjects the applicants a civil Penalty 01 APN u r e ane T
not more than five hundred dollars(S50o). 7 0 9 . Q y y `
❑1,u owner of the property,n my employee with wages u their sole Compensation,
will do the work and the swnum is not intended Cr offered forsake(Sec.7044,Basions
and Professions Cade:The Contractors Lt..law does trot apply to an owner of UI Inspections
pmpeny wlw bei Ids or improve thcmon,end who does such wah himsel f or through his
own employers,provided that such improvements art not intended oroRered forage.IL
however.the building er Improvement is sold within one year of completion,the owner.
builder will has WC burden of proving that he did net build or improve for purpose of
sale.).
❑1,as Owner of the property,am exclusively contracting with licensed contractors to
consumer the project(Sec.7044.Business and Profession Cade:)The Conlraeroh U.
rase law dors not apply to an Owner of Instantly who builds or impruv,es thereon.and
who contracts for such projects;with a conuacmr(s)IienuO pursuant in the Convacmra
wKE" EC D
❑I am exempt under Sec. .B&P C far this moon
Owner Da
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dcelaratimos
I have and will maintain a CesuOcaC of Consent to aalf-insure for Workers Compen- - MAR 15 2004
anon,u provided for by Section 3700 of the labor Cod,for the performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance.a mquined by Section CITY OF I,.UPERTINO
3700 of dm labor Code,for the performance of the work for which this perm b
it is issued. _
My Workers Compensation Income carrier and Policy number art:
amc cT"A�"E�/1�Lk�'F��n,IPaI. � ��3� eros 1� (BUILDING DEPARTMENT
CERATE OF EKEMPTIctB+ttOM WORKERS' I .J 1
COMPENSATION INSURANCE
ClTu section need not W completed if the permit is for one hundred dollars 1$l W)
or Icss.)
1 terrify Out in the perfnnnsnee Of Ne work for which this permit is issued.1 shall not VO4/'�
myperson in mannermaztobccomcabject to Workers'Compensation
Law. A
lsws of of California.Date ✓T11/l
Applinnt
NOTICE TO APPLICANT:If.after making this Ccnincam of Exemption,you should
become subject M the Workers Compensation previsions of the Labor Code,you mus
.J z forthwith comply with Such provisions or this permit shall be deemed revoked.
ZO CONSR
TBUION LENDING AGENCY IV1Y/
Il homer aRthi that there isocd(Sce.30D. agamy rot NC Pcrformancc of
'Ya 7 the work for which Nu Permit u icaucd(Sec.709'1,Co.Civ.C.) 1
ftl 0 Lenders Name f
=z Lender's Address /J
t.J C) 1 cenify that 1 have mad this application and sum that the above information is
LL F comer.1 agree to comply with all city and county ordinances and sum laws mining to
�U building construction.and hereby authorim represenutivcs of Nis City to mixf upon the
} LU ahpve-mentioned to saw,
for demnifti an Purposes.
(We)agme to arc,indemnify and line,may
in ss the City of CupenitC against
F y inconseque consequence
costsandexpanse which may in any way¢nm against slid City /
U z A PLIC uenec of the RSTAN of Nis .it. �f
APPLICANT UL tTIONAN S AND W COMPLY W ALL NON-POINT Issued by: Date /
SOURCE REGULATIONS
Re-roofs
turn of AppliC Conuanor / Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicam or fumm building occupantsort or handke hvasdou material
u defined by the Cupertino Municipal Code.Chapur 9.12,and the Health and Safety
Ode.Scman zssup)7 All roofs shall be inspected prior to an roofing material beim Installed.
❑Yea P P Y g g
Will the applicant or future building«capant WSC equipment or dewmcs wMap If a roof is installed without first obtaining an inspection,I agree to remove
mit harardnus air eontlmietanB u Jcfin by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Ycx
1 have mad the hmardaus materials mquimmenu under Chapter 6.95 of the Califor-
Na Hclth&SarelYCale.Sectors 255(15.25533 ani 1 undersand Nat ifft building
does not Currently hart a Color.that it Is my remmuibility 10 mo il'y oC OCcuPant Of the
e:gaimmcnu wmm xWmetpdo issuance or n Oaf Cceapancy. Signature of Applicant Date
o or aatharc Dam All roof coverings to be Class "B"or better
CITY OF CUPERTINO ""^""� s €aus�s�
BUILDING DIVISION PERMIT CONTRACTOR I�NFQRMATION
BUILDING ERLDING ADDRESS: PERMIT NO
04030074
580 FITZGEIR&T-D DR
R'S NAME: PERMIT ISSUE DATE
MARK & DANE
JNE: SANITARY NO. CONTROL NO.
ARCHITECIENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
. LOO LICENSED CONTRACTOR'S DECLARATION Ib D
FO❑ 1 hemby affirm that I am licensed under provisioof Chapter 9
mencing
ZW ns (comOe$CflIIOn
Pwith Section 7O00)of Division 3 of NC Busitco aM Professions Code,and my license is
o j3<< in full fame anderioct. ADD 427 SQ. FT.
License Class Lic.p
Z F, Dam Contractor
ARCHITECTS DECLARATION
I undersand my plans dull W used u public moods
7yU
0 G Licensed Pn,rcssional
3 OWNER-BUILDER DECLARATION
vehereby ('toI am Ixemprl from Ne CnmmaLicne Law far the
KOO following reason.(Section 1131.3,Business and Profc. ions Code:Any city or county
m which mil a permit I.rnnswn,alms.improve,demolish,or repair any mocmrt
u�'^ poor to its issuance.arm requires IN applicant(arsuch permit to file a signed statement
that Ise is liccused pursuant 10 the provisioms Of dim,COnaWcIOr5 Umm Law(Chapter 9 Sq.Ft.Floor Area Valuation
FFGx
cxSectionW)of Divuio.3ofWBusinssand Pofessions Calk)or
that in,4 exempt therefromrfrom
aM Ne buss for the tllegcd eumpdon.Any violation of
Section 7031.5 by u,,plicent far a permitmbjems N.applicant m a civil penalty or 32 ?NWB@r&er00 Occupancy Type
not more than five hundred dollars(SSW).
❑1,as owner alum property,or my employees with wage as them Wic compcnsNon,
will do die.. ,and Ns.mmut.unot intended mattered forsate(Sec.7014.Business
and Prafessiom Cade:The Commentss Licence law dors Inst apply to an Owner of Required Inspections
pmpeny who Wilds or improves demon.andwho do.such work himselfor Juough his
Own employees,provided that such impros<me.uare not intended decimal for We.if,
however,the Wilding or improvement is said within one year of completion.Ne owned
builder will have the burden of pmving that he did not Wild or improve for purpose of
We.).
�1,as owner of the property,am exclusively contracting with licensed convectors to
contract Ne poi(Sec.1(k44,Business and Professions Cade:)The Conuacmfa Li.
rue law dose not apply man own.of props..,who Wilds or improsm demon,and. -
whoconuacu for such projects with aconlracmr(s)licensed purmanl to the CanuacmYs
Lke^je Law.
Ipm cminpl ander S ,B&P C for this moon
er
OMPENSATION DECLARATION
rtby�fF< JBimnnder�penalty of perjury arc of Ne following dedaratiaos:
1 ham and will maintain a CeNfiam of Consent to selFinsum for Workeh Compen-
sa ion,as provided far by Section 37W of the labor Cade,for do.part....of the
work far which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,m required by Section
37W of One labor Code.far the perfarrome.of the work far which this permit u issued.
My Worker's Cam pencadon Imuranm,carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section Imed not becomputed If the parmit is for one hundred do(lam(SIM)
or less.)
I cerdfy that in the performance of the work for which this permit is issued,I shall not
employ any Iowa in any manner an as m Wcomc subject to the Woracri Comperuation
Laws of California.Dare
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Compensation previsions of me Labor Code,you most
.J O forthwith comply with men pmvi.inm or this permit shall W deemed revoked.
ZCONSTRUCTION LENDING AGENCY
�
P: l hereby aRrm Nu them is a construction lending agency,for the pe mmarroce of
x the wurk far which this permit u issued(See.3091,Civ.C.)
Lender's Name
Lenders Address
U Q 1 certify that 1 have mad this application and Onto that fie above information is
U. P correct.1 agree to comply with all city and county ordinances and state laws mating to
0U building convection,and hereby audmrrae mprexnuuves or this city to enter upon One
}lad
move-mentioned propcny for inspection purposes.
(We)agree m cast,indemnifyandkeep hay in my
City Of againitsagainst
F'h liabiliti(We)greeto cove,and cxpcyandIwhich may inany waytyor Cuaimtsaid achy
UZ in consequence or the granting of this permit.
APPLICANT UNDERSTANDS AND COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE LATION /
J cc__/� Re-roofs
Sign Eutudof APp( HAZARDO IAIS DISCLOSURE Data
Type of Roof
ff Will the applicant or future building occupant stem or handle havardom material
m defined by dm Cupertino M al Code.Chapter 9.12.and the Healm and Sarcry
de.Section 25532(.)+ - All roofs shall be inspected prior to an roofing material bei.
❑Yaa Na P P Y g g installed.
Will me appli,am or Tutors.bud ng occupant ave equipment or devicrs which If a roof is installed without first obtaining an inspection,I agree to remove
it haraMnus air tonna:....as mcJ by IN Bay Arca Air Quality Management all new materials for inspection.
41hNict7
❑Y¢
Ihavc rtaJ the hmaNtmsmaterialsmyviremcn.undcrCNpmr695 of the Califon
'�kia HnaW&Safety Cndc.Sami.duN)5.25 y responsibility
esto atfinndmuicup Wilding
doca'mq.n01 CYRCnI yn no amnan4 mel: ynceOfai hi ity mnotif ymIarm plocy. 11 of Nc
mgairtmone,wmmm� metpri Issas«orae mamorOcapaney. Signature of Applicant Date
caveola(—.ansa..<da �� Dam All roof coverings to be Class "B" or better
CITY OF CUPERTINOh^ v.'
BUILDING DIVISION PERMITzCONTRACTOR4INFORMATION
r`¢3. :�,=:x t✓. •.:neh;§� t> .. ;.1`k�'1meR.sit,- e
6U ll-DING ADDRESS: PE'" "04030074
MIT NO.O 4 0 3 0 0 7 4
21
O'WNER'S NAME: PERMIT ISSUE DATE
MARK & DANETTTE MAVROUDTS
NE: SANITARY NO. '11ii� CONTROL NO.
ARCHITECT/ENGINEER' BUILDING PERM rr INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LOo LICENSED CONTRACTOR'S DECLARATION Job Description
h S
d C I he by afFrm that I am m
licensed under provisions of Chapter 9 Momentin
U with of Division 3 of Ne Business and Professiom Code.and my license is
infull I as freer. [ ADD 427 SQ. FT.
cd.Ca Lie Dole ala `1 " CONTRA OR: FCI CONSTRUCT N, INa(03/12/04�)
p Dale - tpC -
A HITS S DE AT ONS4anderstand my plans sha)be pcd u rp lic mca cla
o ff Licensed Pndcssim al - X111 / �3 OWNERILDRR DECLARATION1 hereby arfirm thn1amexarnpi•fosal Cont, .,'afLicense Law for ft-following memo.(Section]1131.5,Business and` resssi Any city ar�counlyI
m which requires a Pcmlit m canswct,alcor,impmw.demolish.6rrtPucany.;Bupie
FZ< priarN iia iSLllanCC.aI2U fCQuirCa llM]ppllCanl fol SYCh pCr`nIIWEleaslgneds m nl tr'
Nathislicensed Pursuam to the Provisions3the Camrceen;an Cense lsw(ChaPt 0 S FC! loor Area Valu�rdrA' s
ter$ (commencing with Section 7000)Of Division 3 Close Business and Rofessians Code)or �w� �,y 's' "
that he u exempt ftmfmm and the basis for the alleged exempdon.Any violation Cf
Section 7031.5 by any applicant for a permit subjects the applicants a civil Penalty 01 APN u r e ane T
not more than five hundred dollars(S50o). 7 0 9 . Q y y `
❑1,u owner of the property,n my employee with wages u their sole Compensation,
will do the work and the swnum is not intended Cr offered forsake(Sec.7044,Basions
and Professions Cade:The Contractors Lt..law does trot apply to an owner of UI Inspections
pmpeny wlw bei Ids or improve thcmon,end who does such wah himsel f or through his
own employers,provided that such improvements art not intended oroRered forage.IL
however.the building er Improvement is sold within one year of completion,the owner.
builder will has WC burden of proving that he did net build or improve for purpose of
sale.).
❑1,as Owner of the property,am exclusively contracting with licensed contractors to
consumer the project(Sec.7044.Business and Profession Cade:)The Conlraeroh U.
rase law dors not apply to an Owner of Instantly who builds or impruv,es thereon.and
who contracts for such projects;with a conuacmr(s)IienuO pursuant in the Convacmra
wKE" EC D
❑I am exempt under Sec. .B&P C far this moon
Owner Da
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dcelaratimos
I have and will maintain a CesuOcaC of Consent to aalf-insure for Workers Compen- - MAR 15 2004
anon,u provided for by Section 3700 of the labor Cod,for the performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance.a mquined by Section CITY OF I,.UPERTINO
3700 of dm labor Code,for the performance of the work for which this perm b
it is issued. _
My Workers Compensation Income carrier and Policy number art:
amc cT"A�"E�/1�Lk�'F��n,IPaI. � ��3� eros 1� (BUILDING DEPARTMENT
CERATE OF EKEMPTIctB+ttOM WORKERS' I .J 1
COMPENSATION INSURANCE
ClTu section need not W completed if the permit is for one hundred dollars 1$l W)
or Icss.)
1 terrify Out in the perfnnnsnee Of Ne work for which this permit is issued.1 shall not VO4/'�
myperson in mannermaztobccomcabject to Workers'Compensation
Law. A
lsws of of California.Date ✓T11/l
Applinnt
NOTICE TO APPLICANT:If.after making this Ccnincam of Exemption,you should
become subject M the Workers Compensation previsions of the Labor Code,you mus
.J z forthwith comply with Such provisions or this permit shall be deemed revoked.
ZO CONSR
TBUION LENDING AGENCY IV1Y/
Il homer aRthi that there isocd(Sce.30D. agamy rot NC Pcrformancc of
'Ya 7 the work for which Nu Permit u icaucd(Sec.709'1,Co.Civ.C.) 1
ftl 0 Lenders Name f
=z Lender's Address /J
t.J C) 1 cenify that 1 have mad this application and sum that the above information is
LL F comer.1 agree to comply with all city and county ordinances and sum laws mining to
�U building construction.and hereby authorim represenutivcs of Nis City to mixf upon the
} LU ahpve-mentioned to saw,
for demnifti an Purposes.
(We)agme to arc,indemnify and line,may
in ss the City of CupenitC against
F y inconseque consequence
costsandexpanse which may in any way¢nm against slid City /
U z A PLIC uenec of the RSTAN of Nis .it. �f
APPLICANT UL tTIONAN S AND W COMPLY W ALL NON-POINT Issued by: Date /
SOURCE REGULATIONS
Re-roofs
turn of AppliC Conuanor / Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicam or fumm building occupantsort or handke hvasdou material
u defined by the Cupertino Municipal Code.Chapur 9.12,and the Health and Safety
Ode.Scman zssup)7 All roofs shall be inspected prior to an roofing material beim Installed.
❑Yea P P Y g g
Will the applicant or future building«capant WSC equipment or dewmcs wMap If a roof is installed without first obtaining an inspection,I agree to remove
mit harardnus air eontlmietanB u Jcfin by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Ycx
1 have mad the hmardaus materials mquimmenu under Chapter 6.95 of the Califor-
Na Hclth&SarelYCale.Sectors 255(15.25533 ani 1 undersand Nat ifft building
does not Currently hart a Color.that it Is my remmuibility 10 mo il'y oC OCcuPant Of the
e:gaimmcnu wmm xWmetpdo issuance or n Oaf Cceapancy. Signature of Applicant Date
o or aatharc Dam All roof coverings to be Class "B"or better
CITY OF CUPERTINO ""^""� s €aus�s�
BUILDING DIVISION PERMIT CONTRACTOR I�NFQRMATION
BUILDING ERLDING ADDRESS: PERMIT NO
04030074
580 FITZGEIR&T-D DR
R'S NAME: PERMIT ISSUE DATE
MARK & DANE
JNE: SANITARY NO. CONTROL NO.
ARCHITECIENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
. LOO LICENSED CONTRACTOR'S DECLARATION Ib D
FO❑ 1 hemby affirm that I am licensed under provisioof Chapter 9
mencing
ZW ns (comOe$CflIIOn
Pwith Section 7O00)of Division 3 of NC Busitco aM Professions Code,and my license is
o j3<< in full fame anderioct. ADD 427 SQ. FT.
License Class Lic.p
Z F, Dam Contractor
ARCHITECTS DECLARATION
I undersand my plans dull W used u public moods
7yU
0 G Licensed Pn,rcssional
3 OWNER-BUILDER DECLARATION
vehereby ('toI am Ixemprl from Ne CnmmaLicne Law far the
KOO following reason.(Section 1131.3,Business and Profc. ions Code:Any city or county
m which mil a permit I.rnnswn,alms.improve,demolish,or repair any mocmrt
u�'^ poor to its issuance.arm requires IN applicant(arsuch permit to file a signed statement
that Ise is liccused pursuant 10 the provisioms Of dim,COnaWcIOr5 Umm Law(Chapter 9 Sq.Ft.Floor Area Valuation
FFGx
cxSectionW)of Divuio.3ofWBusinssand Pofessions Calk)or
that in,4 exempt therefromrfrom
aM Ne buss for the tllegcd eumpdon.Any violation of
Section 7031.5 by u,,plicent far a permitmbjems N.applicant m a civil penalty or 32 ?NWB@r&er00 Occupancy Type
not more than five hundred dollars(SSW).
❑1,as owner alum property,or my employees with wage as them Wic compcnsNon,
will do die.. ,and Ns.mmut.unot intended mattered forsate(Sec.7014.Business
and Prafessiom Cade:The Commentss Licence law dors Inst apply to an Owner of Required Inspections
pmpeny who Wilds or improves demon.andwho do.such work himselfor Juough his
Own employees,provided that such impros<me.uare not intended decimal for We.if,
however,the Wilding or improvement is said within one year of completion.Ne owned
builder will have the burden of pmving that he did not Wild or improve for purpose of
We.).
�1,as owner of the property,am exclusively contracting with licensed convectors to
contract Ne poi(Sec.1(k44,Business and Professions Cade:)The Conuacmfa Li.
rue law dose not apply man own.of props..,who Wilds or improsm demon,and. -
whoconuacu for such projects with aconlracmr(s)licensed purmanl to the CanuacmYs
Lke^je Law.
Ipm cminpl ander S ,B&P C for this moon
er
OMPENSATION DECLARATION
rtby�fF< JBimnnder�penalty of perjury arc of Ne following dedaratiaos:
1 ham and will maintain a CeNfiam of Consent to selFinsum for Workeh Compen-
sa ion,as provided far by Section 37W of the labor Cade,for do.part....of the
work far which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,m required by Section
37W of One labor Code.far the perfarrome.of the work far which this permit u issued.
My Worker's Cam pencadon Imuranm,carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section Imed not becomputed If the parmit is for one hundred do(lam(SIM)
or less.)
I cerdfy that in the performance of the work for which this permit is issued,I shall not
employ any Iowa in any manner an as m Wcomc subject to the Woracri Comperuation
Laws of California.Dare
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker's Compensation previsions of me Labor Code,you most
.J O forthwith comply with men pmvi.inm or this permit shall W deemed revoked.
ZCONSTRUCTION LENDING AGENCY
�
P: l hereby aRrm Nu them is a construction lending agency,for the pe mmarroce of
x the wurk far which this permit u issued(See.3091,Civ.C.)
Lender's Name
Lenders Address
U Q 1 certify that 1 have mad this application and Onto that fie above information is
U. P correct.1 agree to comply with all city and county ordinances and state laws mating to
0U building convection,and hereby audmrrae mprexnuuves or this city to enter upon One
}lad
move-mentioned propcny for inspection purposes.
(We)agree m cast,indemnifyandkeep hay in my
City Of againitsagainst
F'h liabiliti(We)greeto cove,and cxpcyandIwhich may inany waytyor Cuaimtsaid achy
UZ in consequence or the granting of this permit.
APPLICANT UNDERSTANDS AND COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE LATION /
J cc__/� Re-roofs
Sign Eutudof APp( HAZARDO IAIS DISCLOSURE Data
Type of Roof
ff Will the applicant or future building occupant stem or handle havardom material
m defined by dm Cupertino M al Code.Chapter 9.12.and the Healm and Sarcry
de.Section 25532(.)+ - All roofs shall be inspected prior to an roofing material bei.
❑Yaa Na P P Y g g installed.
Will me appli,am or Tutors.bud ng occupant ave equipment or devicrs which If a roof is installed without first obtaining an inspection,I agree to remove
it haraMnus air tonna:....as mcJ by IN Bay Arca Air Quality Management all new materials for inspection.
41hNict7
❑Y¢
Ihavc rtaJ the hmaNtmsmaterialsmyviremcn.undcrCNpmr695 of the Califon
'�kia HnaW&Safety Cndc.Sami.duN)5.25 y responsibility
esto atfinndmuicup Wilding
doca'mq.n01 CYRCnI yn no amnan4 mel: ynceOfai hi ity mnotif ymIarm plocy. 11 of Nc
mgairtmone,wmmm� metpri Issas«orae mamorOcapaney. Signature of Applicant Date
caveola(—.ansa..<da �� Dam All roof coverings to be Class "B" or better