01090079 (4) CITY OF CUPERTINO °i�•�'*�°°�^+ ''
BUILDING DIVISION PERNIIT &RONTR F, R 1NF�ORMt�TIw nnpp I W
BuIIDINC ADDRESS: WERNER GERTRUDE A P 01090079 a N
OWNER'S NAME PBRMfr LSUEDATE
NE
SANrARY OL NO.
ARCH
BUDDING PERMRINFO
BLDG M=f PLUMB MECH
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ucENSEDmNrnncloR•sDEcuRAnoN IobDescription
1 Itaeey ermt roto I w llcvm Ona«provlilw ar CNpa 9(amnmaakg
i� vlth S«jar Ngq°f Dims ItJafNCBuai nam,tura,of Code.utl myllcene4
LiC. hostac ' COFFERED CEILING IN 'MS . BEDRM.mo, ARCHIIECf•SDECLARATION 1/30/02 EXTEND TILL 7/30/02-NO MORE EXTENSIONS
0 IPmawmmyPoona,"llemccl"Nblkcoatr AFTER THIS . IT WAS ORIG ON THE OLD SYSTEM & WE
u0 Licevcd Pmro.ut.l
OWNER-BUILDER DECI.ARAr10N
1 hereby afrum thto 1 ton eacmp from the Corn .Ilan Law for IW
0 0 following munn.(Sccdmn 711313,BUIn aro,Pwu cija Coac:My city«cwmy
nu fL whlah requUa.Pormi,to amuruct,.lu.hnpraw.acmabh.or mrW,my entamm
iu imm .anq
lro uisa the.�nxm nPet
f« ch it to Rk rca rtua airctvem
d
hw W«n ma
Ubawd NC PUMM t° Porimmu Of thin Conuacwr'a Been¢IAw(ChaPta 9 Sq.Ft. Floor Area Valuation
c (mmmnong%itb Sution 70001 ofD oro 3 athc Buv«a,nil Pwralou Cmc)«
$ thu h U caempt acefmm uM the tui,for tot xlkgm eaa mor.My vkUtimt of
Seals 70313 by mY.ppliuntf«xpemltsebjcaa the xpplt<•^ n.Cirilp®Itya APN Number Occupancy pe
mot more wn Ew lemma aaba(sSOR>.
❑L u owera the popaty,«nry. emplyca with wag-u theb we tmopaetbn.
wiO4 the wort am Ik uruetort boot Inmeded«°Berm far vk(Sac 70th,Bmnaa
.ma Pweao .Cote:rhe comrxaor.I3m.z UW at rot.Pply n m nr a a 0 Required Inspections
plopny wM W IMC«ImPraw�Iheman,and wla Oovueh avk h.�..'r«through hU
inn cmploym,pmNdm WI such Mprmremenu ua rat Inundct areRam f«ul�a,
hmwncr,the eotlding«impowmat b.ad NOert ore yev acmPLtit,me owta�
builder HB Nw t,e W oto a PovUtg But Y db n«boot«imProw f«PWPoxc a
ukJ.
❑I,u awns of the Pmpaty,am uckvwly cmvacting with Ilmtna conv.nan n
a,osooa ttr project(Sar.7W.Ruilnm utrI Proradom Code:)The ComrumMl Li.
c®e Udma.iiply nm.a Popeny wan With.«bribi thcmon,rod,
who cab•^,f«truth Frojcad with.emnu. .,B)limind prow..to toe Cone. e.
Lkcmn lbw.
❑I un eamp utda Sac .B k P C far th4 rc..t �XP�RED
I
« Due
WORKERS COMPENSATION DECLARATION
1 eacby.Bhm under pcimMy of Perjury,one a the fdkmving dalvubm:
1 htaw am will mainuin a cmiliate of Comcm n teffA er«Waters Carnpa
on,u pmviMd f«by Semon 3700 of the Uft,Cmc.fm th perfamtota of the
t for which N,Permit U av-1
I Mn xm will malnuin WwWs Compcmuloo Innrxncc,u mquirm by Smit
0a the lib«Code,f«We xrf«m.na aft w f«w6kE 0dtr permltU lvue6
WO sCmmpamtolea Ima,mme avic am Policy RmmWr.m:
rtier. Policy No.:
CERTIFICATE OF EXEM PILON FROM WORKERS
COMPENSATION INSURANCE
(T7Uracam r¢m u«m camp.r.•t if IW pamn U rartmc eomrm Cogan(g loo)
«kaa)
Iar fy that in Ne permmace a the wart r«wbch th,t Parrott UL ,I.1W1tat
cro"my pco,on In my maerer n u In WimnP objet in the Work.•CPmremtola
Laws of CalDnw..D.e
APpllu«
NOME TO APLICANr:U..fer mating thi.CcniRnte a Fiantpla,yoo IDmmtl
bttax nbjct to to Wog ',Camr,cra bn provitiom of the UW Cmc,you mtu
J 7• roMwith Comply with nth provi W thio,Nrm it> I lr dam d mrmke4
z O CQNSI UCfION LENDING AGENCY
Il,ercby.f Arm thto Nen U.mwruulnn"ngagc«y I.the PC .a
C Lha wort for which Not permit U W«a ISme 3097,Cir.G
AIsmaY Nati
Z' Z LeWels Mlaw
f,0 I cvvfy Nat 1 huw rad NU a Iicaaom xm sue toot the aWw InfmrmtoionU
Contact,l agree to comply with all city am Coity ardin.ruv xm sWeUw reliningn
0U bomm, awmim,toot bereey alloriba mpgeuuiwa or obit,thy b crus uMn ft
W .1,w,a-memiorod Palmy,for imPaaia pWpmea
(We)agme n UM inavnniry ad trsp 1111 a the City OfCtrptttiw agWw
II,I IUMIWa,jmgmcnmccrat xm apew which nuy In my xy tome aplmt nix City
in
U'Z^
APPLICANT ICUNDERS'fAN S AND WIU COMPLY WITH AIL NON.POINT Issued by: Date
SOURCE REGUI.AnONS.
Re-roofs
Stgnumu aAppl HAZARDOUS MATrntAtc DISCLOSURE Date Type of Roof
Mil thm"Haim«funs bmmng oatryw u«c«hartlk havNav m.n.+.t
u Caftel by the CuyvUt Mwb.Spal Cattle.Ceapur 9.12.W the I th am Safety
Care.SeCGmt 25332(x)7
❑Ya r-1 No All roofs shall be inspected prior to any roofing material being
Wit Ne tpplkant oroom Wilding tramp.«=NWrmm or arm wbmh If a roof is installed without first obtaining an inspection,I agree to remove
it hvardous air cnuminma u&lint]by IW Bay Ara Mr Q.ulity Mu honer t all new materials for inspection.
a
❑Ya ❑Nu
1 haw mm tk haaNarmax+laU no aromCms wlkrCbpb Q95of the Ctlifmr
nU HC.IW Q WmyCoae,Sabo 25305,25533 uv125534.1 untemtod thAif ft W iptrtg
dea rot auncmly hme.boar,alto It U my tapmralb111ty n Coaly ft[�a.nt of the
'�obamc.tr boa"°e P° n�Wtoaw'ca a °r° �`y. Signature of Applicant Date
owecr«.POarbW a N IAm All roof coverings to be Class "B"or better