04030057 CITY OF CUPERTINO a a� ..
BUILDING DIVISION PERM "T ,r
BUILDING ADDRESS: PERMIT NOO 4 0 3 0 0 5 7
HER'S NAME: PERMIT ISSUE DATE
BOSSA BE Q� 10 -12004
SANITARY NO. CONTROL NO.
PHONE:
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB PARCH
0 0 0 0
Loo LICENSED CONTRACTOR'S DECLARATION Job Descriptionsdi 1 hcrtby affirm that I am licensed under provision.of Chapter 9(m nomncing
n� with Swe,ma 70M)of Division 3o1'Ne Business and Professions Cma.,rl my license I,
in ten tete,ane ellen' TI--DANCE SHOP
j:.1
n Z License Clens Lk.IS
p Date Contrmor a�
t ARCHITECT'S DECLARATION
�i I understand my plans shall be used As public records
U
is G Licensed Pmfessioml
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt rim.the Conlmcmr's UcAAae Law far the
O O following manna.(Section 7031.5,Business and Professions Code:Any city or county
R$� which requires a permit to convect,eller,improve,demolish,or mpa0 any stme um ,
Fly poor to its issuance.&he requires the Applicantfor such permit to rile a signed statement
y<
that he is licensed pursuant mthe pmvisiomofthe Contractor's LicenseLaw(Chapter 9 Sq.Ft. Floor Area Valuation
y F'$ (commniming with Section70ME of Division 3 oflhe Business and Pmressions Code)or
that he"exempt dominateand the basis fm the alleged exemption.Any violation of
Section 7031.5 by my Applicant for apermit subjects dee applicant in a civil penalty of 3 2W2Tft"d:r0 0 Occupancy e
not more than five hundred della.($500). p y Typ
❑L as owner Alto,property,or my employees with wages AS their sole campen.tien.
will do Newark and on awctum isnotinlended or offered furmle(Sec.7044.Business
and Professions Code:The Committees License law does ant apply to an minor of Required Inspections
propertywhobuildsor(mproves Beeman.end whodoessuch work himselfor through his
own employees,provided Ihatsuch improvements Am not Intended oroRered forsale.If,
however,the building or improvement is sold within one you of mmpledan,the owmr-
buitder will have the burden of proving that he did not build or Improve for purpose of
Aid..).
,
❑1,as owner of the proptng am exclusively contracting with licensed contractors in
construct the pmject(Sec.7044,Business and Professions Code:)The Consacmrs Li.
cense law docs not apply in an owner of pmperty who builds or improves thereon,and
who concocts for such projects with a contractor(s)licensed puovant to the Contraclofs
Licenm Law
❑lam ea rept un rsee. ,B&PCT thi reua�t
n f�
tie % Da¢ '
ORK ' COM ENSATIOND RATION
I& y,d�odm under ally of perjury one of dee following decimations:
1 hive and will malnW n aCcnifimte ofConsenl to self insure for WmkeesComp.a-
Sol!.n.AS provided for by Section 3700 of Ne labor Cod.,fer the performance of the
work fm which this Permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,AS required by section
3700 of the Tabor Code.for Ne perf.mamec of Ne.,it for which this permit I.issued.
My Waraces Compensation Insurance carrier and Policy number am:
Cameo Policy No.:
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This mad.moil not he completed if the permit Is fmisochundred dollars(SIM)
or less.)
1 certify that in the Perri ante of he.,it far wide it is issued,I shall net
employ any o,ina manners to here as a Workera'Compensadon
Laws of Celi R
Applican
NOTI E 0 APPLI I TIEr rrpp ring t is cni0mle of Exemption,you should
been Worke(s Campari gran rovisions of the Labor Cad.,you moat
Oforty n comply such Pmvisiana or Nis permit shall be deemed revoked.
„zr�5CONSTRUCTION LENDING AGENCY
(—i I hereby affirm that then is a construction lending agency l'or the Performance of
Ri the.,it far which Nu Permit is issued(Sec.3097,Ci,C.)
0.Wi A LphoS Nam.
z lender's Addmsa
U C 1 mortify that 1 lawn mad this application and slid that the shove Informadun is
M.H coral I agree to comply with all city and county ordinances and mute laws relating to
0 U huiliing cmnswnion,And hereby amhorim mina enatives of this city to enter upon the
[S7 ahme-no timed property for inspection P.M...
(We)agree to Save,indemnify and keep harmless Ne City or Cupenino agaiml
y
liabilities,judgments.costs and expenses which may In my way aceme against said City
U 7 in consequence of Nc pooling of this permit.
�+ APPLICA ERSTANDS A ILL COMPLY WITH AL NO -P1O}j{NT Issued by: Date -
SOUR EGUL ONS. ,
Re-roofs
signal to Ap canVCo ter Date
C.-
R US MATERIALS DISCLOSUR Type of Roof
Willtheapplica uture building occupamsrore orhandlc harardousmaterial
AS defined by the Cupertino Muni ipaI Code.Chapter 9.13,ane dm Health and Safety
ode.Sc❑cYocna 15533(,)7 No All roofs shall be inspected prior to any roofing material being installed.
' Will the applicant ter sem building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
lhavemadthehmaAr sma¢rialsmquimmenuundcr Chapmr6.95ofthcCalifor-
niaHeSlth&Safct otic.S¢a.ns155(15,15533and15534.1unwc wdthat,tN building
does oat cu y he a mnanL Nm it r ponsrbility m notify wee ter er the
rcyuimm wmmhmstbcmetp' ��0ramar cvp r. Signature of Applicant Date
Als-
owners aamer' agena r Dare IAll roof coverings to be Class "B"or better
*ITY OF CUPERTINO*
• CUPERTINO PERMIT APPLICATION FORM 6 3
APN�Z6 27
113 1' Date: 319/0 _f/
Building Address: /1� Mailing Address (if different from building address):
.21�G 3lfr' r &u.k Ila. car 41 990
Owner's Name: Phone# "
�A�� CAd—TFa2 - t5OSSA�'e IL Ov- 96a-9�9
Contractor: Uohn License #:
— �2..
Contact:�A� � , Phone: Cupertino Business License#:
Fax:
Building Permit Info: p�
Bl Elect�❑ Plumb LJ- Mech er
Job Description:
Residential ❑ Commercial gz&/ (f,�r!/
Sq.Ft. Floor Area: 1900
$/Sq.Ft.: 1,900
OQ
Cost of Project: / U Occupancy Group:
Type of Construction: v a
lk this box if the project is a
s con o addition: ❑
Quanti Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu, MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX lnd/Off/Comm/ uasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
lo f3 2t
� e
OITY OF CUPERTINO
CUPEY10 W7 PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain & Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL.
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platfomi Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Sips, Marquee ELECTRICAL
2 of 3
*CITY OF CUPERTIN(O
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quantity Fee ID Fee Description Fee Group
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING j
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Insection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
i
i
i
3 of
1
ti,� �PoynaA COGL FIRE DEPARTMENT CONTROL NUMBER
iR.F a� SANTA CLARA COUNTY o1 d
• 14700 Winchester Blvd., Los Gatos, CA 95030-1818 pER T NUMBER
(408) 378-4010(phone) • (408) 378-9342 (fax)
PLAN CHECK No.
PLAN REV-IEW COMMENTS /J D
CODE/SEC. SHEET NO.
The following CHECKED items apply to this project:
B Existing fire sprinkler system shall be modified as necessary. A licensed C-16 fire protection
l contractor shall submit to the fire department, three sets of shop drawings, a completed permit
application and applicable fees for review and approval, prior to performing work. UFC 1001
Existing fire alarm system shall be modified as necessary to accommodate new construction.A
licensed fire alarm contractor shall submit to the fire department, 3 sets of shop drawings, a
completed permit application, and applicable fees,prior to performing their work. UFC 1001
2 Tenant shall have access to a m;n;mum of22AlOBC minimum rated fire extinguisher(s).
Travel distance to nearest extinguisher shall not exceed 75 feet. UFC 1002
Tenant shall have access to one Class 'W" type fire extinguisher, within 30 feet of commercial
cooking equipment. Post sign near"Y"extinguisher noting commercial fire protection system
should be activated prior to using the portable fire extinguisher. UFC 1005
• N 3 Exit doors shall be openable from the inside without the use of any special knowledge or effort.
Thumb-tum dead bolts that require more than 1/4 tum to operate are not acceptable.UFC 1207
Exit Illumination: Provide illuminated exit signs. UFC 1212
Contractor shall field verify the integrity of existing rated construction/assemblies and restore or
'fir dd repair as necessary as part of this work. Penetrations in rated walls/ceilings shall be protected
by listed fire rated assemblies (dampers, doors, caulking, fire stopping material etc.). UFC 1111
e At time of final inspection, the tenant shall.provide to the fire department a labeled emergency
access key for placement in the building fire department key box. UFC 902.4
This plan check does not permit the use,storage or dispensing of hazardous materials,operations
or waste. The tenant shall provide a completed FIMM to the fire department's hazardous
materials specialist for review and comment. Furthermore,a CLOSURE PERMIT is required prior
to terminating the storage of hazardous materials at a permitted storage facility. Demolition of
any facility/storage area that previously stored hazardous materials shall not be approved
prior to obtaining a CLOSURE PERMIT.
APPROVED FOR BUILDING PERMIT ISSUANCE subject to compliance
with the above checked comments prior to final inspection.
JURI$ p PLANS SPECS NEW REMODEL AS CONST.DESCRIP. BY qqq ,, _(//��((^/ DATE PAGE
'SEC/FLOOR OCC OCC.LOAD AREA ARCH/E G/CONTRACTOR/OWNER
C'97 77 d
M NAME OF FACILITY LOCATION
Q
5S ,4 E L L /} Z / 2 to q 8 7 CA 4,0,
A California Fire Protection District serving Santa Clara County and the communities of
Campbell, Cupertino, Los Altos, Los Altos Hills, Los Gatos,Monte Sereno, Morgan Hill,and Saratoga
r
THE OAKS CENTER « PIAN
Stagy. Create >iiad. • 0up• 408 662 saw
,L \ i��t: 860 SLE ar
\ +w.o e.•"" cuporum, Cetfpaapfa emur and,
4" 057 M07 e
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CHECKED ,rs'.', l
DATE
PLA0
INI�. uF 'Ta
DATE
BLDG. DEPT,
Gyp,^-Als to deck abO
New 3.'D'doors tD back storage
oGypdessing room
dbes I ErAFF x 24'0
Ma*ply.31eachng
rd6vam edge.
Line of w.311 abn fires"room I SW
& talt bmndcvr per 0ln wistrucCiona
6G'H Utp half vml
1.5xB"Maple top.
ti 60-11 GP t.4f wall
8-(I
-(ILIJ ReWrrn
5"x S'Maple top &jp wall to snfft abs Gfyp wall w SOfft dt)(Ne 36- l
24" 24' 2A'
Replace cbor
vWlth WURAM Replace-window Repiamcloor
with roars with Wtidm
IVc4e:Field nreasin•e amd oordimm location of e u
waft with the O�r belove llabricati� 2.Ili
Plan Set Oars 850-539.7550
1/8- NEW WALLS Cita Jeff Gant
OFFICE COPY K
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2001 CALIFORNIA BUILDING CODE
FIGURE
Lr,
C
EA CENTERLINE
C CENTOERLINE CENTERLINE
1,
L Ac FIXTURE FIXTURE FIXTURE FLUSH
L A ACTIVATOR -
L,n IB^ 18• ON WIDE
L A 9 N. SID
Lc
LA ^� H W
L A L TO�EyDGE
L A FLUSH O 0 WAT ` OCLOs R
L n ACTIVATOR - CLOSEf \
L C ON WIDE -
L c SIDE
1. C1, Ato
L A U
• I.C
L \
A
C
is 7g" MIN
L A 18' I MIN. CLEAR
L A MIN. CLEAR
LA _
LA MULTIPLE TOILET STALL
L 1.c SINGLE OCCUPANCY TOILET
LA
LC
LG
LA
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LC
L
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LA
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L A
L C 16-01 BAY APP0.0`1EOVE D 3.69P
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L C �9.OYAe HAY
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1.L A .
C ALL DiHPYN9xYH ® —
L A ♦10'MAY TO "
L C xIDNYHT 118_-9AXLE
L A PAYi ?
LC
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LC
LA
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THESEOIAOREGULATONS ANGONSTRUG ON ONL IAS AN AID
. ETHE
j Oon THESE DESIGN AND
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L C FIGURE 11B-1A
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SCALE 1/4"= IRAW SET ;;t
DATE:3WJD4
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REFAIL DESIGN
'U"Ieff Gra
858539.7550
2 A:Storegej Office: A-1:Upstairs office/ B:Front Counter
Add: storage Core floor for power and cable
Phone Add. Set power at back of millwork on 12"post
2 1 D Base T Phone Confirm locations based on cabinet dramn95. o
A DSL 10 Base T Add: '
Check vath Omer for DSL Phone
-2 2 locations and feed info. Check vith Owner for 1 O Base T
A2 lacations and feed info. DSL
Chalk and confirm with Dane:the location=_
2 and feed info.
2 2 4 ds' l 2 :
B a
2 _
UrIi7COPY
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- �furisx 99 D outlet set at 42°-AFF o
3 . . � ..._I� lam,
Plan Set Date 31-04
Scale 1/13 = 1' POH✓ER/CABLE Afxn:Jeff GrsnL
L 01-ITI NG KEY o
2'X 4'Ruorascant
lamp set at 10'AFF
3"D x 3"x B" i 00 W Chandeliar ager shoe seating set at T AFF
Aluminum egg crate _
drfFuse,rs
50VV Pendent lamps sec over wood floor at 8 AFF
75W PAR3O Adl mini gimbal A4 0
track fiawres.sat at 1 OWE n 50W Pendent lamps sat aver ccunir_r at T AFF
\Mnite finish
Set in windows as high and as 3611M14OW Cosmetic tight strip
close to window as possiWe tg�
- set overdress!ng room marcors at
whJe Stell sHoinnng fixuara to f BO"HdoMu
swivel
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`clan Set Data 31-04 PRELIM. 858.539.7550
Sale'���B"=1' FIXTURES Atttt Jeff Grant
CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,CfJ1T.itAkCpR.I�iI�fRMATI4 ', :.
BUILDING ADDRESS: PERMIT"04030057
'ER'S NAME: PERMIT ISSUE DAM
BOSSA B
ONE: SANITARY NO. CONTROL N0.
ARCHITF.CI'/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
moo LICENSEDCONTRACI'OR'SDECLARATION Job Descript,rrt� �� ®
V 1 hereby affirm Nat 1 am lienal under proviaiom of Chapmr 9(rnmmewing
with Section 70011).!Division 3 of the Real.and Profcestmis Cade,and my]!CO..is
in full tome and effect. TI--DANCESHOP JUN
{�
Lf9Z Licen.Cl.s Lk.g JUN 21 20Oat'fT
Jr Dam Centimeter
ARCHITECTS DECLARATION
1 understand my plans¢hall be used as public records ��'�®'��
3 w Liensed P d.asio..I
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law far the
p 0 following....(Section 7031.5,Business and Professions Code:Any city or county
x m which requires a pewit to construct,alter.improve,demolish.or repair my structure
FZi prior to its Income,also requires the applicant for such permit file a signed atsmment
< tli is licensed pumuanlm the provisiomofthc Contf.sor's License ww(Chapmr9 Sq.Ft.Floor Area Valuation
i2zp� (commencing with Section 70M)of Division 3 of Ne Businessund Professions Code)or
3 that M is e.mpt therefrom.d Ne basis far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant.a civil Finally of 3 2VB7RV11td'SIer0 0 Occupancy Type
out mom Nan five hundred dollars(3500).
❑La sownerof and
property,mmy employedwithwagesa tile(Sm.co ,Busies
will dathework.and Wswdum icats Lictude Law does
7004,Business
and unywh bis Code:The Conmctees ndwim Uw does not apply tom owner is Required Inspectors
propertywho.,Ido ori d Chaves thereon,and whodoessuch work himself ed.rough his
Own employs,providedmrovemimis mid ntsamnot intendedoroRered tanto IL
however,ma building or improvementg that a within one yam of improve
par the owner-
builder will Mw the burden of moving Net he did not Wild w improve fon pugmm of
oak.).
❑T,a owner of the property,am exclusively contracting with lienal contractors in
Construct the project(Sec.7W,Business and Prafesdons Code:)The Contractors Li.
cerise Law time not apply in an owner of property who builds or improv shaman,and
who contracts for such projects with a conwc.r(s)slimmed pursuant to the Commences
Lice..law
❑lam mptun rSec B&PCC. mi rwa�
if Dam 0
ORK CO ENSATIO D RATION
IW w under sity of perjury ane of me following dxtamtions:
I have and will maintain aCo i fcatdof Consent to self-Insure for Workers DomPcm
sasion,as provided for by Section 3700 of the labor Code,for the performance of the
work for which thio Pewit is issued.
❑I have and will maintain Worker's Compensation Insurance,.required by Section
37M of the Labor Cade,for the performance of me work for which this permit is issued.
My Warker's Compensation Insurance caller and Policy number am:
Cmier. Palley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This.ction need nolbccomplemd If the pewit Is forearm hundred dollars(SIM)
or less.)
1 lenity Net in me perf onceof he work for whit Anis is issued.l shall not
employany o ina manner nbec cat t Whrkeri Compensation
Laws of Cali c ti ,
APPl
NOt'1 6 E 0 APPW i REn)t ding n u cenificaa of Exemption,you 0..at
bora hiker's Cam .tion rovisions of me lab.Cade you..at
z toM a comply such provisinna m Nis permit shall be deemed mmkoad.
.zi O CONSTRUCTION LENDING AGENCY
I hereby effw that them is a construction lending agency for to performance of
rl 7 the.,it for which this permit is issued(Sec.3197,Civ.C.)
ALendees Name
z Lender`s Address
UI certify that I have mad this application and state met the be.information is
D. Fcomet 1 agree to comply with all city and county ordinances and Aare laws relating to
V building Construction,and hereby authodmrepresenativesofthis city tocn.rupon the
4kI above-mentioned property for inspection purposes.
(We)agree I....indemnify and keep harmless the City of Cupertino against ���sss
M liabilities,judgments,costs and expenses which may in any way¢echo egsinat said City
V 7 inconsequence of me granting of this pemit. /
A APPUCA ERSTANDS A ILL COMPLY WITH AL NO -PO T Issued by: Date
SOUR EGUL ONS.
(J Re-roofs
Sig!etA o Ap canuiC actor Dam
H R S MATERIALS DISCLOSUR Type of Roof
Will she eppli i tort building occupm store or handle hammous material
defined by the Cupertino Muni'pal Code,Chapter 9.13,and the Health and Safety
c,Sead.35533fU7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea o
Will me applicant or Wro buuaimg ocatFanl a.equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I,havardour air contaminants a defined by the Bay Area Air Quallly Management all new materials for inspection.
Dis0ict7
Yes
I have real the havadt smamruIsmquimmcros under ChapterG95ofmcCalifor-
niaHcalth&Soret otic,Swdors ZM5,2533=d2534.lun&c dthatifLb Wilding
does not c y It a mnent that it' r poosibdhY m notify . .t or�J
rectum which.stbcmet fcam of sup y /a Signature of Applicant Date
Owner err authhr' again Date--"'TV All roof coverings to be Class "B"or better