12110045CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10331 LOCKWOOD DR
CON•FRACYOR: ROYAL SERVICES
PERMITNO:12110045
OWNER'S NAME: JONES IVAR N AND SANDY
2253 MAYWOOD AVE
DATE ISSUED: 11/082012
OWNER'S P110NE: 4086211359
SAN JOSE, CA 95128
PIIONF NO: (408) 972-2452
❑ LICFNSF,D CONTRACT'OR'S DECLARATION
.TOR DESCRIPTION: RESIDE\ I'IAI, CO\NIERCIAL
License Class G��h Lic. q yl(G 6 y
CHIMNEY REPAIR FROM ROOFLINE UP—NA//'�-B
!'�OYCj�f<'e5
Contractor- Date
hereby affirm that I am licensed tinder the provisions of Chapter!)
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full farce and effect.
hereby nffnrm under penalty of perjury one of the following boo 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
Sq. F( Floor Area:
Valuation: $3000
performance of the work for which this permit is issued.
1 have and 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
APN Number. 34230033.00
Occupancy'I-ype:
permit is issued.
APPLICANT CERTIrlcAT10N
I•certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN ISO DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
TION.
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
180 DAYS'FROM LAST CALLED INSPE
costs, and expenses which may accrue against said City in consequence of the
Z
growing of this permit. Additionally, the applicmn understands and will comply
Issued by: / / 1 Date: 11
with all non -point source regal t hs per the Cupertino Municipal Code, Section
'
(/
9.18.
r�
�z
RE -ROOFS:
Signature Date f p
All roofs shall be inspected prior to any roofing material being installed. If a roof is
- -
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
_
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
hereby' affirm that I nm exempt from the Contractor's License Lawfor ane of
the following two reasons:
ALL ROOF COVF,RINGS'I'O IIF CLASS "A" OR RETITR
I, 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,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
11AZARDOIJS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I hove read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth & Safety Code. Sections 25505, 25533, and 25534. twill
I hereby affirm under penally of perjury one of the follmoing three
maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the
declarations:
Ilealth & Safety Code. Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined be the Bay Aren Air Quality Management District 1
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code. Sections 25505, 25 and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
permit IS ISSUCd.
Owner or authorized agent Date:
,
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
CONSTRUCHON LF;\DING AGFLN
become subject to the Worker's Compensation provisions of the Labor Code, I most
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
works for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANTCERTI FICATION
Lender's Address
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
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
A HG l ITF,Cr'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional '
9.18.
Signature Date
CUPERTINO
CONSTRUCTION PERMIT APPLICATION la
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE ° CUPERTINO, CA 95014-3255 I` U
(408) 777-3228 ° FAX (408) 777-3333 ° buildinGna cupertino.orct
❑ NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/ DEFERRED ORIGINAL PER,\11Td
PROJECT ADDRESS _ 3 I APN K
✓J 10r003_S
;2
OWNER NAME 1v0z
II IC'l� u�e5D
HONE C2/
1 14
E-MAIL
STREET ADDRESS i CITY. STATE, ZIP
I FAX
CONTACT NAME V/EC PHONE 4.06 t?71 V' E-MAIL
STREET ADDRESSCITY•STA
E. ZIP
FAX
DOWNER 0OWNER-BUILDER ElOWNFRAGENT VICONTRACTOR 13 CONTRACTOR AGENT ❑ ARCHITECT 0ENGINEER 0 DEVELOPER 0TENM7
CONTRACTOR ( E �• LICENSE NUMBER.
"ion R AI( X. rVI CBS �G�/ LICENSETF
I BUS. LIC9 OAP"
Y11r-!C C 2
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS �S .°t w✓,,.0 a /� U
v
CITY, STATE, ZIP
�'h
PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER
BUS. LIC q
COMPANY NAME
E-MAIL
FAX
STREET ADDRFSS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
g
C(n /
E)GSTIN9 USE
/:�-17
PROPOSEDUSE
CONSTR. TYPE
eSTORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION (s)
EX6TG
NEWFLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODELAREA REMODEL AREA
PORCH AREA DECK AREA TOTAL DECKTORCH AAEA
GARAGEAREA:DETACH
GATTACH
eDWELLING UNITS:
IS A SECOND UNIT FI
BEING ADD ED? fK0
SECONDSrORY GY E9
ADDITION?
2�'R
/G
PRE -APPLICATION OYES DYES,PROVIDECOPYOF
PLAItNBNGAPPLM I � PLANNING APP0.0\'AL LETTER
ISTIIEBLDGAN YE$_
EICBLER HOPIE!
RRECE1V BY: S�-.7e >. - Jl'
Y• 1°'ice ;,. ,` (t".T�
TOTAL VALUATION:
Jr`T'+QO
-�•
By my signature below, 1 certify to each of the following- am the property owner or authorized agent to act on the property owner's behalf. 1 have read this
application and the information I have provided is corre I arc read the Description of Work and verify it is accurate 1 agree to comply with all applicable local
ordinances and state laws relating to building nstruct' n. authorize representatives of Cupertino to enter the above-ide tifie property for inspection purposes.
Signature of Applicant/Agent: Dare:
SUPPLEMENTAL INFORNIA I ION REQUIRED
'•iq •I'.`I! x c�'e� R0
- R�""T`W `
'_f NOUTINQSIiIP •.•
New SFD or tt4ultifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
P 9 P
•Mg j �O.- - • i+�
° Ii reJE couvE� , ,
-_ 4�``rr '"` i'
` V - 1. . ' r
Rbuu DiN i I.A.. RL\1LW
r `
r*-e't,
permit for new building. `
i P
❑P. LU REss�
y.,y..7x'slbt +•'S'
1-�9rlan�ncrt:An Re\ IE\Y
_''�S
_ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
g P
form if any Hazardous Materials are. being used as of this
®h •�`N .e
AtsT to �� �' � x�
Y t
❑ .Ivnuct\oal.s
pan project.
�L±Ji'1 RL DFII
_ Copy of Planning Approval Letter or Meeting With Planning prior to
submittal of Building Permit application.nfy?§;
ttAJON
®E ni iRvset\EN DISTRIcr
^.�i.tc-..--o-x_.t�a„i-iay.lC
.•FjUE\\ IHONMENTAL HEALTH�YPe'.
BIdg9pp_20/ I.doc revised 06/21/11
CITY OF CUPERTINO
la%I FEE ESTIMATOR—BUILDING DIVISION
NOTE: This estimate does not includejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer.District, Schaal
District. etc.). There lees are bared on the Dreliminarr information available and are onlr an estinnate. Contact the Dent for adifn'I into.
FEE ITEMS'(Fee Revolution II -053 Elf 711112)
ADDRESS: 10331 Lockwood Dr #B
DATE: 11/08/2012
REVIEWED BY: Sean
Mech. Permit Fee:
APN:
BP#:
'VALUATION:
1$3,000
*PERMIT TYPE: Building Permit
PLAN CIIECK Tl'PE: Alteration / Repair
PRIMARY SFD or Duplex
USE:
Elec. Imp. Fee:
PENTAMA'rION 1CHIMNEY
PERMIT TYPE:
WORK
Chimney repair from roofline up.
SCOPE
$0.00
NOTE: This estimate does not includejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer.District, Schaal
District. etc.). There lees are bared on the Dreliminarr information available and are onlr an estinnate. Contact the Dent for adifn'I into.
FEE ITEMS'(Fee Revolution II -053 Elf 711112)
Atech. Plan Check
Plumb. Plan Check
rlec. Plan Check
Mech. Permit Fee:
Plumb. Permit Fee:
rlec. Permit Fez:
Other Afech: lny.
Other Plumb Imp.
Oder Elec. last). Ej
A -tech. bap. rec:
Plumb. hup. Fee:
Elec. Imp. Fee:
NOTE: This estimate does not includejees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer.District, Schaal
District. etc.). There lees are bared on the Dreliminarr information available and are onlr an estinnate. Contact the Dent for adifn'I into.
FEE ITEMS'(Fee Revolution II -053 Elf 711112)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
1 1 #
$534.00
Chimney / Chimney Repair
ICPUMNEYR Chimney Repair
Suppl. PC Fee: (D Reg. Q OT
0.0
hrs
$0.00
x
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee -.0 Reg. Q OT0
0
hrs
$0.00
PME'Unit Fee:
$0.00
PME Permit Fee:
$0.00
Consuitction Tin-:
Administrative Fee:
O
E)
Work Without Permit? O Yes Q No
$0.00
Advanced Planning Fee:
$0.00
Select a Non -Residential
Building or Structure
I
E)
O
Trace/ Documentation Fees:
Strong Motion Fee: IBSE/SMICR
$0.50
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$1.50
$534.001TOTAL
FEE:
1 $535.50
Revised: 10/01/2012
ADDRESS: 19858 Baywood Drive
APN:
_8PL'D\1lI-I• TVPR
Dhimhinn Permit
BP4:
DATE: 11/21/2012 REVIEWED BV: Sean
'VALUATION: $600
PI..I N.CFIRr1:.TV PF: Alteration./.Addition./-Repair.
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19858 BAYWOOD DR
CONFRACFOR-PATO BE
PERMIT NO: 12110125
c aNED
OWNER'SNAME: PARADY SHARON E TRUSTEE
I K l.. C
DATE ISSUED: I V21/2012
OWNER'S POONE: 4082075545
PIIONF. NO:
JOB DESCRIPTION; RESIDEN PIAL LJ COMMERCLU,❑
❑� LICENSED CON'FRACI.OR'S DFCLARALION
License Class GLic. # qSV 3IxJ
REMOVE AND REPLACE I IN. WATER MAIN
'r/C I/ Al -L
SEE NOTES
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business S Professions.
Cade and that my license is in full force and effect.
hereby affirm under penally 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
Sq. Ft Flour Area:
Valuation; $600
performance of the work for which this permit is issued.
1 have and 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
APN Number: 3163101 _.00
Occupnnq•'I'ypc
permit is issued.
APPLICANT CERTIFICATION
1 cenify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 D M LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accme against said City in consequence of the
(IZt
Issued by: Dale: 112
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
/ ,// _ _
RF: -ROOFS:
Signature `�`–' Date / 2 1-2—
All roofs shall be inspected prior to my roofing material being installed Ifo roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
hereby affirm that 1 nm exempffrom the Cmuractor's Liecnsc haw for one of
the following two reasons:
ALI, ROOF COVERINGS TO BE CLASS "A" OR RF,I'fER
1, as owner of the property, or m• employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business R Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
IIA7,ARDOIIS JLATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth S Safety Code. Sections 25505. 25533, and 25534. I will
hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Ilealth S Safety Code, Section 25532(x) should I store or handle hazardous
1 have and will maintain a Certificate of Consent to self -insure for Worker's
material. .Wditionally should I use equipment or devices which mimic hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defiled by the Bay Area Air Quality Management District
performance of the work for which this permit is issued
will maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Ilealth S SafelyCudc. Sccti '55115, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date t 2
permit is issued.
1 certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
--
Compensation laws of Califamia. If, after making this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm than there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CF.RTI FICATION
Lender's Address
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 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 stave
ARCIIITECI'•S DECLARATION
indemnify and keep harmless the City of Cupertino against Iiabdities,judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 1q-`
(408) 777-3228 • FAX (408)777-3333 • buildinc cncuo=_rtino.orc
�/J?L'UM31NG ❑ h4ECriA.*p:C.4L ❑=LEC.PJCAL ❑MISCELIAN'cOUS
M E P
m'sc
7R01B?A]DPs3S /I � 06-k
a" I A"N" I C.O
V la
OW-NERNAME
r/
S i72;=i IDDAE55/(J'(/� �%
tl L\.GvA
c"Y. sqr
FAX
CONTACT NAME ' �^ V I D
n'1V j'♦b 17t"
PHONE /"U
E.M,VLn
S.T =i. DRZSS `
CrrY, STA,-- ZP
FAX
Wry ❑ OWNS-BUl!DER
❑ OWNER AGENT' 1.TAAROR 11 CONTRACTOR AG -7, ❑ Alk=—CT ❑-VGaT ❑ DEV--EL0PER ❑ .TZ?4 17
COhiAACiOR NAME
LI
LICENSENUNSER
UCENSE TYPE
I EUS. LIC:
CON3ANY NAPM
EMIL*
FAX
SFR==.ADDRESS
I CiTY,STAT=,L?
I FHONZ
ARCTCT/NG7+"F=R NAME
UCENSc hU1'sZ
I BUS. UC ,#
CID N_'A-W NAA^:'
E -I/ II'
FAX
SIR=_. ADDRESS
I CITY, STATE, IIP
I PHONE
BunD^_a0: ❑WNY_RCUL ElMi1LhFAMD.Y
I M. -AN WTWA_ AREA NO
FIMDZON'_❑NO
I 1.r—tHOMFI ❑NO
D'cSCiTTION OF WOR%
E/+'!D ✓ /Yi SAG R `
A �✓LZ ��
TOTA_ VAT UAMN': Ov
��
I RECEIVE BY:
By ny signar_te below, I ce: d;y :o ezcn of 1�c following: I am the prope�y oWma or aut.Sonzd agent to ac: on the pmpe, cvmcr's behalf. I have r_ad ;his
app Ecadon and the infomtation I have pr '' is cL I hzve read the Description of Wod: and verify it is acCWZIc. I ag.-- to comply with all applicable local
ordirmccs and state laws relating to '> • $g bns io, I u•horizc representzdves of Cuprino to enter the above-idati5c4prone:,y for irspccdon puI?oses.
SiFw'a1^_of ApnliczndLgen[ Dzx: II�2= J!2
INFOIZM_.',TION REQUaED
•
OFFICE USE ONLY
p
u
,
V
z
OVER-THE-COUNTER
❑ EXPRESS
❑ STANDARD
❑ LARCE
❑ MAJOR
&=?!4uc4pp_2011.doc revised 06/21/11
6.�
PME Plan Check:.
$0.00
CITY OF CUPERTINO BUILDING III, RIMIT I
BUILDINGADDRESS: 10146ALPINEUR CONTRACTOR: KS EI.EC'IRIC PEAM1'1';NO: 12110097
OWNER'S NA\IF: IIEONCIIULR• SOO K PARK 1072 NORFOLK OR DATE ISSUED; 11/1512012
OWNER'S PIIONE: 4082053107 SAN JOSE, CA 95129 rnONE NO: (4UN) 568-0928
.❑ LICENSED CO\ IlL\CI'0RpS DECLARATION
License Class //�—�� Licc,, k-
Contractor 7. Z7— Ce 4,2C Date
I hereby alYnn [hat I am licensed under the provisions of Chapler 9
(commencing with Section 7000) of Division 3 of the Business &P rofessions
Code and that ray license is in full Force and effect.
I hereby affirm under penallyof perjury one of the following wyu declarations:
I have and will maintain a certificate of conscn[ to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performancc of the work for which this permit is issued.
I have and 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.
APPLICANT CER'TIFICA'TION
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 laws relating
to building constmetion, 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.
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulalions per the Cupertino Municipal Code, Section
9.18.
Signature li// Date lZ—l) �� L
❑ OAVNlilt-BIIILDEit DECLARATION
I hereby affirm that l an, exempt from the Contractor's License Law for one of
the following I%%o reasons:
I, as owner of the property, or my employees with wages its their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sce.7044, Business & Professions Code).
I hereby alTirm under penalty of perjury unc of the following, three
declarations,
I have and will maintain a Cer ificate 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
I certify that in the performance of the work for which [his permit is issued, I.shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, alter making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICAN'l CER' I'I F[CA'TION
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 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,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additional]y, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Date
BUILDING PERMIT h\FO: BLDG r ELECT r PLUMB r
AIECII r RESIDENTIAL r COMMERCIAL r
.1013 DESCRI P'TION: ADD NEW METIiR 17OR COAIhION ARRAS-BII.I.ING ONLY
Sq. Ft Fb...I Arca: I Valuation: S200
APS Number: 32615105.00 I Occupancy T) PC:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued Ir�� Date
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all nese materials for
inspection.
Signature of
Date:
ALL. ROOF COVERINGS TO I31S CLASS "A" OR BETITIR
HAZARDOUS INIAT'.RIALS DISCLOSURE
have read the hazardous materials requirements under Chapter 6.95 of the
California Health S Safely Code. Sections 25505. 25533, :in(] 25534. 1 will maintain
compliance wilh the Cupertino Municipal Code, Chapter 9.12 and the Ileallh S
Safety Cock, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality \l: nagemenl District I will
mainlain compliance with the Cupertino Municipal Cude. Chapter 9.12 and the
Health S Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:
CONSTRUCTION LENDING,%GP.SCY
I hereby affirm that there is a construction lending agency for the performance of work's
Ibr which this permit is issued (Sec. 3097, Cir C.)
Lender's Name
Lender's
A RCI 11TE.CI"S DI?CLARA"PION
I understand nu}• plans shall be used as public records.
Licensed
CUPERTINO
&,� 5W11'/ --
GENERAL PERMIT APPLICATION I r l E P
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 w I
(408) 777-3226 • FPX (408) 777-3333 • buildinorcDcuD=_rfino.oro / /q�� I\e�'
n PLUTIMBING n."ect.PNC.4L FKI'L=CM]CAL I—IMISC=LI.ANF0I3S
io
OWNER NAME PHONE E-MAII. .
V6 g D
STAT=TADDRESS
CaiY l -,p
FAX
CDNTACT NAME r ' /
P??Oh= E-MAIL
S-, R-E7.4DD?MS
CrrY, STA',
❑ OwA'3 ❑ OwNER-ButLOER ❑ OP'h^u wGEN7' P-CON,—Ii =R ❑ CONFPACTOR ACEhT, ❑ Axam=T ❑ Dn,zLoPER ❑ 7B4Ah7
CO*71-4CTOR NAME LEI�L
I LJCENSENU7-3ER ZZ
uCa'SE ME^
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I BUS. LIC FOS ((/
CON.PANY NAI S
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A-ChTcCT/LNGSNEr7t NAME /)
llCENSE NUNSM
I Bila. DC S
COWANYNAME'
E-N.Ay
FAX
S7iLE7 ADDRESS
CITY, ST.4 i; IIP
USE OF ❑Sri .DU?LEX ML1TIfF Y
BUTDNG: ❑COMMERCIAL
PROIECrp1WD-DWJD ❑ 13 PROJECT DI ❑ YES
LABAN TN`MTACE AREA ❑ NO FLOODS ❑ NO
IS it_BLDG AN ❑ 1Y3
EIOD_'A HOME? ❑ NO
DESCRHnON OF WORC
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TOTALvALUAnON: Zoe,
RECD`1D 9Y:
3y my signxm-e below, I "ni i to each of :he following: I am :he prooecy owner o; ratho:ized agent to act on the propey owner's beFali. I have sad this
applicazon and the iTo-x:ion I have ntvided is co^.CL I have rend �'& Dcsripdon o: *Wo -.k and vci y it is ac=mm I zgree,ro comply wi:.i all applicable local
or din=s and state lzws relating to building ccnsSactim I ap:hor'n , nzdv o�-jCnxr:ino to enter the above-idm:i5cd nLrox-+:or inspection put;noses.
Sig:a .of .ApplicanJP.g=c 4: ��' `4.�"`-� Dare:lT—
SUPPLEMELI AL INFORMATION REQUuZFD
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OFFICE USE ONLY
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L- O-11 A THE -COUNTER
❑ EXPJU',SS
❑ STANDARD
❑ L4RCE
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.AjZPM4c4pp_3011.doc revised 06121/11