00110109 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADD1��5S PRIVIRTNO
15 VIRGLNIA SWAN PI_ PETERSEN—DEAN INC 5101. 1.0].09
OWNER'S NAME. Al"Lfi:AI'ION SUB 1]/,\'f s
J. C. INVESTMENT 'GROUP 7980 ENTERPRISE DR 1. 1./c�/2000
PHONE: (510) 494-9982 SANITARY NO. CONTROL NO.
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ce o ARCHITECTiENGINHEIR: BUILDING PERMITINPO" ❑❑ BLDG B18Cf PLUMB MECH
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IiD Lorvred undid s urcLARAnaN Job Description
O Z_ I tion 70 0h of That am of fe J ander pnd won,of Code.mad my Iwm%c .
ata l--a with fall Section of Division?nfthe BusinevsanJ lYnfesniunsCWc.ani mylicense
�x-� i.inrunma,eana � SHAKES TO MONIER DURALITE
doh Liaanse Cl c r7-9 Lie.ar 7
3 LL Dale / L a/ (_amCL
H O A,,h IWise .,,addRADON
I unJemmaJ Iny..runs shall be u>eJ as public rccoNs
pSO Licensed Professional
a..f OWNUR-BUILDIiR DECLAIlAI]ON
YI=o, I hereby affair he,I.,it exempt from the Contraerors 1:cense Low,fa the
C?< Iidlowing reason.(Section 7131.5.Business anti Prulessions CtNc Any city crummy
Y F p which nNaims a laund to cont.but. It r,militate.demolish. pa y structure
_M&/ /7
i3 oro pnnrt t c also y :Ihapplicantf such c tin fl signed statement
hat he is I cern ed formal I the polls kions of the Contractors 1 sun Law(Chapter 9 Sy. Ft. Floor Area J V
commencing 'th Sect I Mica Division i f theBusiness ec J I f ions core) J G
or that he is corolla durefnn t and the basis for IM1e alleged exicti .Any vbl:nam
of Section 7031.5 by:any applicant fill a 11,1111 subjects aIle applicant Ina s'ivil oally
of am mom than live[itrmlred dollars($5001. , APN Number 'cupancy Type
o L axnwn„nfit,ptopcity,or nay eaplayces will wags as meirno �.
lc cmapa,alit,n• 31.64601.5. 00
will Jo the work and the smarm,is not intended or oRcred for sale(See.7044,
Business and professions Code.The Cammror's License Law,does a"'apply m m Reynlred Inspections
uwner of property Who builds or implicates,thereon,and what tlms such work himself 305 — FRAME
or through his own employees,..-,.tied that such improvements art ata intended or
oBcml for sale.If.however.the building or innpmvement is sold within one year of 307 — INSULATION
Incompletion.the owner-builder will hwe the burden of proving that he did not build or
n..rove forpargal.ofsale.). 601 — ROOF TEAR OFF
1:11.a of me property.no exduosely contracting wim icer\cd ,t
et,r oaem ,to 602 — ROOF. PLYWOOD NAIL
Lmgmcl the project(Sec.70,14,Batinvs n professions Coal It,Cl moors
icense Law does analply to an on net of property who builds or replaces hereon, 603 — ROOF PATTENS
and who atei'Awa,pmeeswimaennrmror(s)licensed nrrtmmme 604 — ROOF IN—PROGRESS
❑1 am exempt under Sec. .B A P C far this mason
pa'ner Date
WORKER'S COMPGNS6I'ION DECLARATION
I hereby'"'ander ps"'yf l
oe.jury ore..P tier following de"ne"lona,
❑ 1 have and w111 r intain u CertiBcme of Couseno n,self-insure Ina Wnrke2s
Cnmpemmio r. as punaled fur by Scrinn1 3700 of the Labor Codfo
e, r the
perl'onn ul..f the anal,lir which this peronit is issued.
have ani will maintain Will Compensation Insumnce,as reyuined by Section
t7p(1 of the IuMr Calc,for the perli,rmunce of Ibc work for x'h¢h This pvmnit is
issueh
Cn1Y A�er�x Gnnpenvlinn Insumna curriWr and Po/•li�cy(�Jnumhe rc C
rd
,at LCL,( .1,If tJA'I'li)N l)113XI�MI+PION IItfMN'ORKFZ�ffU�
COMPENSAnON INSURANCl3
("is section need not w completed if the permit is for one hundred dollars
IS10d)or Icss.)
1 certify that in me performance of the work for which this fiction is issued.1
shall not employ any person in any manner ul as to become wil to the Worker'
Counci ion I.nws of Calitomiu.Dale
Applicant
NUI'ICE TO APPLICANT:It,afar making this Ccrtiliellc of Exengnlon.yen should
h,,i r abjec,to the Wm kill, orn
Cpcmmlon nn,lil n'nalthe LaMa
r Colo.you ain't
Oforthwith,amply x'id,x,let ........ions or ihls ,,all .hull be deemed revoked. .
FCONSTRUCTION LENDING AGENCY ..
�. 1 hereby aff nn that them is a eommuctlon lending agency for the performance
of the work for which this vomit is issued(See.3097.Cis'.C.)
[) Len'll Name
5 z Lendcr'c Address ,
U C 1 cmi IT Ilmr I have read this applla!Ilion lad stat,diol IM1e abuse intbnomion is
W F, encu.1 agree to ctnnply wim all city and...un1y onlirl and somelass"ml'adng
[) ,build'mg conxuuc,iuread ei,hy commitu nprc>untativcc oflh,city tocntcr neon -
Ihe oho e-buteloned no,ttly for indwelon proposes.
t}. L M'elagme ts.mv.indemnity keephmn,in the wayal'upeninn.,am,,sid
In liabilities,juJgn¢nlx,,nils and expefxs which rnuY in any way accrue ngaina said
U z City incnn"greme of e gmnung of tins peemrd.
APPLICANT}IN S \NDS AND - .L COMPLY WRH ALL N— Dale O ,�CJ
I URCE(�}�/ c.ATle. // D 0 V Issued by:
Srgnam,c Et Aliprrmb am..is, D:ne Re-roofs
U "'Do"""1311111.1 DISCLOSURIi
Will the applicant or future building urri,cll1xo,handle haanot rnmerwl Type of Roof
as Jefincd by the Cripenino Municipal Come:Chapter 9.12,and the Hcuhh and Safety
Cade Section 25532(u)1 I/Iv/
ayes o All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building usndenm use equipment or devices which If a roof is installed without first obtaining an inspection. 1 agree to remove
emit haeardous air conmminatns us defined by the Bay Arca Air Quality Management
D"nee e>� all new materials for inspection. Applicant understands and will comply with
oyes all non-point source regulations.
1 hair tend the la,naduu, reatedal,u !'order CI',n 'f.JS it the
California He'hh K Safety Cad Sections 25505.2.5533 aJ 25534.I nallarsdand thol
if the haildingJ I currentlyb real rdent )ne,lily. IIythe �—Jl �� Q 0
occnpam o'f thhy.nqu - i whish nu w prior to:.asses t 1 u Cvr Bwm of
tiea..a"`,yam Signature of Appl' ant Date
Dneaa(Jathnri:xJ All roof coverings to be Class "B" or better
OFFICE