12100149 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10584 WHITE FIR CT CONTRACI'OR:FOUR SEASONS ROOFING PERMIT NO: 12100149
OWNER'S NAME: DAMODAR PRASAD H AND DAMODARA SASI PO BOX 1668 HATE ISSUED: 10/192012
OWNER'S PHONE: 4082721333 SAN JOSE.CA 95109 PHONE NO:(408)278-0130
❑ LICENSED CON RACfOR'S DECLARATION' gU1LDINC PERAf1T INFO: 13LDC r ELECT C, PLUMB r
LicenseClass Lic.H /(/O
DIECII r RESIDENTIAL r COR@IERCLAL [I
Contmemr Date
hereby affirm that I am licensed and the provisions of Chapter 9 3OR DESCRIPTION:RE-ROOF,REMOVE SHAKE&INSTALL PLYWOOD AND
(commencing with Section 7000)of Division 3 of the Business S Professions COMP
Cade and that my license is in full force and effect. SI INGLES 13 SQ CLASS A
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. ,
I have mid will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$4500
APPLICANT CF.R'IHr16rf10N
I certify that I have read this application and slate that the above information is APN Number:35905124.00 Occupancy Type:
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may aceme against said City in consequence of
granting of this permit. Additionally;the applicant understands mid will comply WITHIN 1 ) DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section Igo DAY M LAST CALLED INSPECTION.
9.1n/85.
I�FAlgrai� \^ Date Issue Q b Date:
❑ OWNER-BUILDER DECLARA'T'ION
hereby affirm that I am exempt from the.Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
T,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code) c
I,as owner of the property,am exclusively contracting with licensed contractors to 4S' natumApVto, Date:l
construct the project(See.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the folloiring three ALL ROOF COVERINGS TO RE CLASS"A"OR RF ITER
declarations:
I have and will maintain a Certificate of Consent to self-Insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health S Safety Code.Sections 25505,25533,and 25.534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code.Chapter 9.12 and the Health&
Safety Code,Section 25532(x)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work forwhich this permit is issued,I shall contaminants as defined by the Bay Arca Air Quality Management District 1 will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of Colifomia. If,after making this certificate of exemption,I Healt -Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensmion provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. r or au orcd r r
APPLICANI'CF-RT'IFICATION CONSI'RIICI'ION LENDING AGENCY
I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances mid state Imus relating I hereby affimr that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to sane Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may aceme against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITEICI"S DECLARATION
9.18.
1 understand my plans shall be used as public records.
Si_enature Date
Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
" ADDRESS: Q5R(-{- WV._;:/ DATE: 10/18/2012 REVIEWED BY: jsg
APN: BP#: 'VALUATION: 1$4,500
•PERMIT TYPE: Minor Building Permit PLAN CHECK TYPE: Re-roof
PRIMARY PENTAMATION
usE: SFD or Duplex PERMITTI'PE: 1SFDWLR00
WORK Reroof, remove shake instal plywood and comp shingles
SCOPE
FEEID ROOFAREA
(s.f.)
1REROOFFRES 1,300
Mech.Plan Check Plumb. Plan Check Ele, Plan Check
• blech. Permit Fee: Plumb. Permit Fee: Floc. Permit Fee:
Odrer•,tsech.Insp. Other Plumb Insp. Ll I Other Elec.Insp,
Esech.Insp.Fee: Plumb. Irrsp. Fee: Flee.Insp.Fcc:
NOTE:.This estimate does not include jeer due to other Departments(i.e. Planning, Public H'orks, Fire,Sanitary Sewer District,School
District, etc). These fees are based on the prelintinan information available and are only at estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 Elf. 7/1/12) FEE QTY/FEE DIISC ITEMS
Plan Check Fee:
Suppl. PC Fee
Plvmh./.Ale ch.lF_lec
Permit Fee: $195.00
Suppl. Insp Fee
Plamh.I.Hech.lElec
Plumh.lA2ech.lElec Permit Fee:
Consn-uction Tax:
Administrative Fee:
Work Without Permit? 0 Yes Q No $0.00
Advanced Planning Fees:
Travel Documentation Fees:
i
Strong Motion Fee: IBSEISA11CR $0.50 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
z S $196.50 $0.00 TOTAL FEE:', $196.50
Revised: 10/01/2012
.. .•y - l Z I o� � � j
EaREROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
C LIPERTINO (408)777-3228- FAX(408)777-3333 • bulldincSScuoertino.ow
PROJECT AD DR /\� G AP?= n (x/12 � o� _
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-'Ow"iP ❑ OWNER-a011.1313t ❑ r)WNF-RAGENT Jif CONTRACTOR ❑rOMPAC'TV0.AGENT ❑ ARCHFFECT ❑ CNOINP.CR ❑ D°VELOPEA ❑ TENANT
CONTRACTOR NAVE rear S'¢OsGn$ L LICIiN$2VL'1111ER ,2 too I.ICF.NSE(•,ice(` -E DUS,LICK �13 aZ3
COMPANYNAMM
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ARCtifrECT/ENGINEER NAME I LICENSE NIIAM I BUS.UQF
COMPANY NAME E-.NAIL FAx
STREET ADDRESS I CITY,STAMZIP V PHONE
USE OF 17 SFO or Duplex Af Multi-Family ROOF.AREA: vALVATION,
s RucnRr:: ❑ Commercial 3 $ J W SQ
LYISING ROOF TYPO: 11BUILT-Ur ROOF ❑ASPII.ALTSHINOLCS ONVOODSIIAKFS ❑WOODSHINOLES ❑01 HF:R ISPCCIFY)
RLMOVR/REPLACE YFS fF FO. PL:"w'OOD "i'^ ❑ I PLYWO O OSS PITCH: ROOF
❑ N n YF.RS 'C S. ❑ s IlJ}I',= DX 'I z s'
PROPOSED ROOF TYPE: ❑RCILT-UP ROOF J11CkSPHALTSHISGLES 0WOODSIUIKES ❑WOOD SHINGLES COTHP.R. rCC-ES REPORT9
DESCRIPTION OF WORE;
oOct
Jwood� 6aa-3o
C_4L�w n��ac1 PTL CdG IPA—�oMO P.S�SLo.IDl_Cru G. a
9y my sirnn[ute below,I ttM1ify to tech n,`thc frlimvlag; I am the property omvner or autllorrud agent to act on the property owner's bchalL I have read this
application and the information I have provided is correct. I nave read the Description of Work and verity it 11 acCUMte. I aglcc to comply with all applicable local
ordinances and state laws relating m building cons tian. I a terizc rPr tiv•S OfCupeeine ro enter the nbove•Idemitled property`or inspecdon purposes.
Sigrature of ApplicenVAgem: _ Dam: I It sa[a
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
If building is associated with a(dome Owner's Association.provide letter Plea CHECU TYPE Ro1mrvC 51,116
of approval from HOA. ❑ OVRR-THF:C•OIIh'rTR ❑ 811)LSINC PLANK EW
Provide PlannlaLq approval N verify if there any r[Stric!iOn S. ❑ Fj(PRFZN ❑ PLANNING PLAN REVIEW
- Provide copy of Manufacturer's Installation Specifications. ❑ srrnnw.ao CI mRcon"
T Provide signed copy ol'Cupertino's TcarrOff Policy. ❑ OTHER:
Rerogf.ipp_2011.doc revised 03/l6/l 1
REROOF TEAR-OFF POLICY
0 COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
ALBERT SALVADOR. P.E., G.B.O., BUILDING OFFICIAL
10300 TORRE AVENUE - CUPERTINO. CA 95014-3255
CU,PE RTI NO (408)777.3228•FAX(408)777-3333-building(a)cupe ino.ora
rnaec npgRrQq nrN.
ER NACCal1G�p r `u� �_,„J ,� � 6-Mni4
STR6ETADDRESS CI TAT 14 FA.'(
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CONTRA .AA}C LIC6\ F,AlIS/BER/l` LICF,V rE 9115. .n
Co. NAp1E E-MAIL V FAX
STREETA�I�F�( CI '.SQA E. IF O mea
10
J v I UNDERSTAND AND AGREE TO THE FOLLOWING:
I. The re-roof project shall comply with all applicable provisions of the 2010 California Codes.
2. An inspection request can be scheduled up to the day before the inspection date. Please call (408)777-
3228 from 7:30 - 3:30pm (Mon-Thurs) or 7:30 - 2:30pm (Friday) to schedule the next day inspection.
For Tcar-Off and Nailing Inspections, you must also call on the day of the inspection only after that
phase of the work is completed. The building inspector will be available within one hour. Progress
and Final Inspections will be given a two hour window.
3. Tear-Off Inspection is required. Any and all dry-rotted wood shall be replaced prior to this inspection.
Unless new plywood roof sheathing is proposed throughout, all the nails/fasteners shall be either
completely knocked-down or removed prior to this inspection.
4. If plywood is installed, a plywood NailinZ inspection is required.
5. Roofing shall not be applied without first obtaining all prior inspection and written approvals from the
building inspector. Any roofing which is applied without first obtaining an approved inspection will
require the removal of all new material down to the sheathing so a proper inspection can be performed.
6. Proeress Inspection is required when approximately 50% of roof covering is installed.
7. A Final Inspection and approval shall be obtained from the building inspector when the re-roofing is
completed. To receive a final sign-off, the following items will be verified:
a. Flat roofs shall have a minimum of/" per foot of slope and demonstrate there is no ponding.
b. Listings from approved testing agencies for all pre-manufactured products used shall be
available on-site to review at the time of the inspection.
c. Proper spark arrestor installation, vents painted, gutter/downspouts installed, debris removed.
8. NOTE: If you call for a tear-off or plywood nailing inspection and the work is not complete; you will be
charged a re-inspection fee of S 126.00. The re-inspection fee shall be paid before another inspection
can be scheduled.
By my signing below, I certify each of the Following is true: t am the property owner nr authorized agent to act on the
property owner's behalf. 1 understand and agree to comply with the rc-roof policy stated above. I also understand that
smoke detectors and carbon monoxide der rs re required to be installed in accordance with Sections R314 and R315 of
the 2010 California Reside 'a de.
signarure of Applicanvn cn ' Date:_
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CITY OF CUPERTINO
FEE ESTIMATOR — BUILDING DIVISION
ADDRESS: 10243 Glencoe Dr DATE: 10/22/2012 REVIEWED BY: Sean
APN: BP#: 'VALUATION: $5,600
*PERMIT TYPE: Plumbing Permit PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY PENTAMATION
USE: SFD Or Duplex PERMIT TYPE: 1RPSS
WORK Property line clean out.
SCOPE
APPLIANCE/EQUIP TYPE FEE.ID QTY UNITS RP FEES
Sewer, Sanitary 1PRSEWER 1 # $23
TOTALS: $23.00
Mech. flan Check Plumb. Plan Check 0.0 hrs $0.00 Elee. Plan Check
Mech. Pernria Fee: Plumb. Permit Fee: IPPERMIT Elec.Permit Pee:
Other Mech.Insp. Other Plumb Insp. 0.0 hrs $45.00 Other Flee.Drsp.
Mech.Imp.Fee: Plumb. htap.Fee: Efee.Insp. ree:
NOTE. This astinmte aloes not include feav clue to other Departments(i.e. Planning, Public Works, Fire,Sanitary Seu'er District,School
District, etc.). Thesefees are baser/on the prelintinan'.information available and are onh'an estimate. Contact the De t or ac/(ln'I info.
FEE ITEMS (Fee Resolution 11-053 Eff 771/12) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
Supp/. PC Fec
PME Plan Check: $0.00
Permit Fee:
Suppl. Insp Fee
PME Unit Fee: $23.00
PME Permit Fee: $45.00
Construction Tar:
Administrative Fee: 1.IDMIN $42.00
Work Without Permit? O Yes Q) No $0.00
Advanced Planning Fees:
Travel Documentation Fee: ITRA PDOC $45.00
Strong Motion Fee: IBSEISMICR $0.56 Select an Administrative Item
Bide Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $156.56 $0.00 TOTAL FEE: 1 $156.56
Revised: 10/01/2012
ISG ( 0 L) I ]�`�
GENERAL PERMIT APPLICATION M E P
- .. COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 A I
GUPERTINO (408) 777-3228 • FAX(408)777-3333 • building0cuoerino.ora \vJ' va
/ PLUMBING ❑ME Kk1;rICAL ❑ELECTRICAL ❑MISCELLAN-EOUS
PROECTADDREs
OwNc-'ti NAI✓.E
U A
5 T RE-i ADDRESS . 5T e /1�' FAX
CONTACT NAM'e (' I E-MA:7
FAX
O Wn� ❑ 0w -SUBDZlt ❑ OWNER AGENr' ❑ CONTA/.CrOR ❑CON' CTOR AGc/ . ❑ ARCr=rCr ❑D+ca-Ek ❑ DEV--n.oP;A ❑ -*ANT
// CONTRACTOR NAM' C- EPS •� I LICENSE TYPE BUS.LC p
\/ COMPANY NAME / E-MAIL FAX
lye
STREET ADDRESS �,1 STA Ji3/I P
ARCHITiCLENC1KEEER NAME I LIC7- 'SE Ml)✓=k BLS.LIC R
COMPANYNAM=' E-MAR FAX
STREET ADDRESS CITY,STA',ZIP PHONE
USE OF OU SFm OUPI iY ❑ MU FAMRY I PROSECT IN W'_DLAND 0 YES PROSE IN ❑YES I SF °S
TSLOG AN ❑ Y
BUILDING: COMM cIAL URBAN INTERF�FACE ARNO FLOOD ZONE ❑40 EIIOD_R HOME] ❑NO
DESCRIPTION OF WORK
TOTAL VALUATION: r N- N - RECENED BY: - - - -
Hy my signave below,I cry;o each of Lie folleaing: I as the property owner or anchor ized agent:o zc:on:he property ownc's behzif. I have:,zd;his
application and the information I have provided is CO=CL I have read the Descrlptioo of Work and verity it is xee:rate. I agreq to comply with all applicable local
o:dinmc- and sate laws relating' building c racdon. I authorize r-pr- nati+s of Cupertino to enter the above i ati5_d ppcl:or inspection pui�',�oscs.
Sign==of ApnlicandAgene Dare:
SUPPLEMENTAL TNTFOR-MA 1 ON REQURED OFFICE USE ONLY
❑ OVER-THE-COUNTER
Y
❑ EXPRESS
V
❑ STANDARD
V
a
< ❑ LARGE
❑ MAJOR
.>CF.Vua4pp_2011.doc revised 0621/11
✓ SUBCONTRACTOR BUSINESS NAME BUSINESS LIC-El
Cabinets & Millwork
CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10270 SCENIC BLVD CON1'RACI'OR:SOLARCITY PERMITNO: 12100046
ON;N I.R'SNADIE: DICKERSON TERESA A 3055 CL1i,\RVIEW WAV DATE, ISSUED: 10/082012
OWNER'S PIIONE: 4083141497 SANMATEO.C\ 94402 PHONE NO:(650)638-1028
LICENSED CON'1-RACI'OR'S DE/CLARATION BUILDING PERbII'T INFO: BLDG [ ELECT T� PLUMB
r
License Class —/0 C— 6 Lie.# 2Q9119 7
) D /L DIECII (— RESIDENTIAL r COMMERCIAL r
I herebtor P-C/d Date
1 hereby affirm that I em lie used under the provisions of Chapter 9 30ft DESCRIPTION: INS'T'ALL 50 A RECEPTACLE IN GARAGE FOR CAR
(commencing with Section 7000)of Division 3 of the Business&Professions CHARGER
Code and(hat my license is in full force and effect
hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a cenificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq. Ft Floor Area: Valuation:$800
Section 3700 of the Labor Code,for the performance of of the work for which this
permit is issued. PVT
,U'N Number:35708048.00 OccupancyType:
nrrLICANr cr•.R•rlFlayruyN
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state Imus relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmlesstheCityofCupertinoagainstliabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City inconsequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additiouallv,the applicant understands and will comply \
with all non-points rce reg s per the Cupertino MunicipWC;ode, lim 7`9'18' Issued by: t. Date:
Signature Date '0 �
❑ OWNER-BUILDER DECLARATION RP:ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
(lie following two reasons: inspection.
h as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS•1'O BE CLASS"A"OR ISP.ITER
hereby affirm under penalty of perjun.one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of(he
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505.25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safely Code,Section 25532 a should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for h}' ( )
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
Coll[am its its defined by the Bay Arca Air Quality Management District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25.505.25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation lass of California. If,after making this cenificate of exemption,I Owneror u Cirnlzer g 1:' 0
become subject to the Worker's Compensation provisions of the Labor Code,I most �Vb (late:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRIK—FION LENDING AGENCY
APPLICANT CF,RTI FI CATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state Imus relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City ofCupenino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCI I I 1 LCIS DECLARATION
ION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall he used:¢public records.
9.18.
Licensed Professional
Signature Date
i
;2 —
yl
R.ECEIVE7> Circuit Specifications 1,LM, p Y
OCT 0 0 2012
BY:
Customer Name:Teresa Dickerson eo
_ JB-950923 ; YI
q~ Address: 10270 Scenic Blvd
ea Cupertino, CA 14
F ��E GO tg ! Servce4.1497RatOng: 200A �;rl Dvw
Circuit Voltage, amperage: 240V,40A
COMMUNITY DEVcLCPA'E,tTDEyyire Size/Type:N8 AWG,THHN-2
BUILDING DIVISION-CUPEuri,yc
Circuit Breaker:50A, Murray MP250220CT2
APPROVED Electrical Equipment: NEMA 14-50
This set of plans and specifications MUST be kept at the
Job site during construction. It Is unlawful to make any
changes or alterations on same,or to deviate
therefrom,without approval from the Building Official.
The stamping of this plan and spsclfi,aryons SHALL NOT
be held to permit or to be an as)aroval of the vlolatbn
of any provislons of an,
BY O/C)
DATE /D- 'e ' 2-
--- (E)125A Main
PERMIT NO. �LIC C> Panel
i
i
I
3/4"Conduit
I
(N)Nema 14-50
Outlet
GENERAL PERMIT APPLICATION E
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 w A '
CUPERTINO (408)777-3228 • FAX(408)�-3333 • buildina(a cuoerino.ora '\v/' J
❑PLUMBING ❑MECHANICAL LEC.TJLICAL ❑MISCELLANEOUS
PROJECTADDRESS dZ4 f'CenIZ- RIJ.d. I A3N�L� J - D - 0
O�V74ER NAME Teres ot. -bI Ciker.P6r
PHONE �� J/I/r�'I 11/`� (c/MP.3.
""'RES'
1.2-70 SGCvn c- RIA, I CCN GiA. �I'1.6.71 1 I "6� / I FAX
CONTACTNAME Ca /B' >��t-� ( CITY.
PHON�- .�p,222-3( Gbon���So%trG'� - gip
57-REFI'ADDAE55 Y
� � .SfATE, ZIPc^N FAX
❑OwI R EINOw -BUBDER •❑ OwxERAOEM ❑ CONTRACTOR 10 RM =�RIA ❑ ARCFTCi ❑7cI7EJt ❑ DEVELOPER El TENANT
CONTRACTDRNAME ( I LICENSE NUMBER LILC'�.'lo C�6 I BUS.UCd .
COMPANY NAME I I '(y/ / / E MAi a8 / r / FAX
STREET ADDRESS l l� CRY,STATE,ZIP PHONE
MRNµ- 0_.S C.O —
ARC?UT=C T/FNGA-Er71 NAME / LICENSE NUMBFA / / / 1 / 8115.LIC.Y
/
COMPANYNAME' E-MAB. f/ FAX
STREET ADDRESS (/ / I CTTY,STATE,rB I, / / PHONE
USE OF ❑GlfM DUPLEX ❑ MiR FAAfD.Y I PROJECT IN WtLI)LAND O❑ Yzs / PROJECT IN ❑ YES ISTHEBLDGAN ❑ t'ES
BUII.DPIG: COMMERCLAL URRANO„TERFACEAREA NO FLOOD ZONE ❑ NO MtDMER HOME? ❑ NO
DESCR. . ONOFWORX
TOTAL VAL UATION:YI�O I RECEIVED BY:
By my signature below.I<eniryto each of the following: I am the p perry owner or authorized agent to act on the prope y owner's behalf. I have read this
application and the iafom:ation I have pro�nd- ct 1 ha -• the Description of W'o:ic and vmfy it is aecurzte. I xg:<q�o comply with all applicable local
ordinance and sate laws relating m build' cion. I a d c representatives o`Cuoerino to enter the above-i nr1nfi< property for inspection puiposes.
Signamro of Applicant/Agent: Date: ��d��
SUPPLEMENTAL.INFORMATION REQUIRED OFFICE USE ONLY
❑ OVER-THE-COUNTER
}
❑ EXPRESS
❑ STANDARD
U
Z ❑ LARGE
❑ MAJOR
Ad P.,ucApp_1011.doc revised 06/21/11 -