02080149WITY OF CUPERTINQ*
PERMIT APPLICATION FORM
AP N � ,3 D Date:
I _
2 02
Building Address:
10,550 Lei+! 1 r IJ E I,t1f�
Owner's Name:
Phone #:
DDtrF— L STEJE SHED
461S 2-5-7 -Cog 01
Contractor:
License #:
A L A J
BUILDING
Contact:
Phone #-
LA O
—7233
Applicant/Contractor:
Fax.,.
BCONSTAXR
tvsd� �J
o Bu
g Permit Info:
BId
Elect Plumb ech
Jo escription:
esidential: M F—C—Commercial:
Sq.Ft. Floor Area:
$/Sq.Ft..
Architect/E.ngineer:
Valuation:
A
Energy
Type of Construction:
Occupancy G
Energy Add Multi
r
!2uantity I Fee ID
Fee Description
Fee Group
BAPPLOTHER
Other Appliances
MECHANICAL
BCONSTAX
Construction Tau
BUILDING
BCONSTAX
Ind/Off/Comm/Quasi
BUILDING
BCONSTAXBQ
Con. Tax for BQ Zone
BUILDING
BCONSTAXII
Hotel and Motel
BUILDING
BCONSTAXR
Constax — Resi/Mobile
BUILDING
BELEC1000
Elec 600V <= I000A
ELECTRICAL
BELEC1001
Elec 600V > 1000A
ELECTRICAL
Elec Svcs 600V <= 200A
ELECTRICAL
I)IBELEC200
BENERGY
Energy
BUILDING
BENERGYADD
Energy Add Multi
BUILDING
BINVESTIGA
investigation fee
BUILDING
BMITIGATC
Comm. Housing Mit. Fee
BUIL.DLNG
BMITIGATR
Res. Housing Mit Fee
BUILDING
BMNEWMULTI
New Multi -Family Res
NECHANTICAL
BN-EWMULTI
New Multi -family Res
ELECTRICAL
BNUCOMME
New Comm Electric
ELECTRICAL
BNUCOMMM
New Comm Mechanical
MECHANICAL
BNUCOMMP
New Comm Plumb
PLUMBING
of
CITY p
CUPEkTINO
CITY Or CUPERTINO
PERMIT APPLICATION FORM
a
2,a y o'b 7,r
APN # `� !�
.. . -�o --, - 7
Fee ID Fee Description
Date:
`Building Address••:..
MECHANICAL
BCONSTAX Construction Tax
BUILDING
Owner's Name \
BUILDING
Phone #.
'-te
D
Cont r etor:
License #:
BUILDING
Contact: -ff
A -f eL n
BCONSTAXR Constax—Resi[Mobile
Phone #:
Applicant/Contractor;
ELECTRICAL
Fax #:
BELEC1001 Elec 600V > IOOOA
ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A
ELECTRICAL
Building Permit Info:
BFNERGY Ener
BUILDING
Bldg Elect
Plumb
Mech
Job Description:
,-�
B[JILDTNG
Residential:
o rct ;27
BUILDING
Sq.Ft..Floor Area:
BMITIGATR Res. Housing Mit Fee
S/Sg t.:
BMN'EWMULTI New Multi -Family Res
MECHANICAL
BNEWNNiULTI. New Multi -family Res
Arch) tect/Engineer:
Valuation
3p�
Type of Construction:
y_X
BNUCOM1v M New Comm Mechanical
Occupan
up.
Quantity
Fee ID Fee Description
Fee Group
BAPPLOTHER Other Appliances
MECHANICAL
BCONSTAX Construction Tax
BUILDING
BCONSTAX IndlOfflComm/Quasi
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 > IOOOA
ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A
ELECTRICAL
BFNERGY Ener
BUILDING
BENERGYADD Energy Add Multi
BUILDING
BIN VESTIGA Investigation fee
B[JILDTNG
BMITIGATC Cotrnn. Housing Mit. Fee
BUILDING
BMITIGATR Res. Housing Mit Fee
BUILDING
BMN'EWMULTI New Multi -Family Res
MECHANICAL
BNEWNNiULTI. New Multi -family Res
ELECTRICAL
BNUCOMME New Conun Electric
ELECTRICAL
BNUCOM1v M New Comm Mechanical
MECHANICAL
BNUCOMMP New Comm Plu b
PLUMBING
92 m"Mr, =I,
-:174t� -A..4.A.- us:e
1 of 3
,jel / ? 67�
OF
CI BUILDI
CONTRACTOR INFORMATION:
G DIVISIONPERMIT
BUILDING ADDRESS:
PERMIT NO.
10550 WHITNEY WY
02080149
Qr ME:
& SHEILA DOLEZAL
APPLICATION SUB DATE
08/26,2002
lg PHONE: s`
SANITARY NO. CONTROL NO.
ZO ARCHITEC7UENGINEER:
BUILDING PERMIT INFO
p
BLDG ELECT PLUMB MECH
t�
L-1 L=
a
Z LICENSED CONTRACTOR'S DECLARATION
Ihcn:70affirm mminm aundersines previsions Piofssi Chapter,a commencing
Job Descri t
MASTER BATH REMODEL pPHNALEO
ridden
with Section a and e f Division 3 of me Business and Professions Code, and my license
is ce full tome and eHcn.
License Glaax Lie.. •
O
Date Conwaor
H ARCHITECT'S
MAR 0 3 2003
DECLARATION
g 1 understand any plans shall be used as public records
BUILDING
Licensed Professions] OWNER BUILDER DECLARATION
1 hereby affirm that 1 1. exempt from the Contractor's Professions
oe: Any c ty o for the
M following reason. 7031$ Business dna Professions Code: Any city or county
$30000
ex Permit t
❑ which rite it a permit m comwct, aha improve, demolish, ore any awaurt
ing
^� prionostheuadpuntaosaquirce thovisios
for suchpetmiuoicese Lawdmuspter9
- - ------ --- ---
Valuation
- mlFashcpnsNpbrs no the piovisiomofNeConmecmfsLcenxlaw(Chaplar9
of
(commencing with5 a 7")of Division 3 ofthe Business Professions Code)
and
or that he is exempt therefrom and the basis fnr the alleged exemption. Any violation
y �at
of Section 7031.5 by any applicant for a pamdt subjects this applicant to a civil Penalty
.of tan am than five hundred dollars (s500).
101 APNFh4LR ODATI ON
Occupancy Type
01, isowner of me pmpeny. or my employees with wages as their sole compensmion,
102 PIERS
], O3 — UFER Required Inspections,
q p
—will do me work; ad the structure isnot intendedor offered far sale 7844;
business' and'Prefeeaions Cade: The Comracmr's License Law does not apply to an
owner of progeny who builds or improves thereon, and who does such work himself
104 — REBAR
or through his own employees. provided mm such improvements ue not intended or
offered for sale. IL however, the building or improvement is sola within one year of
.. . 10 5 -—...ANCHOR - BOLTS._•.• 1. • .: ...', -' .,..
ompletion, the owner -builder will have the burden of praying that he did not build or
improve purpose o
10 6 - SEWER & WATER
1.
r
� h u owner of ilio progeny, am eadusivelY <omxting with Ii cense) conwnon to
--—202' -'-UNDERFLOOR- PLUMBING— ;-_l_ ... ...... ...._...
i
consumer the project (Sec, m . Business and Professions Code:) The Contractor's
203 - UNDERFLOOR MECHANICAL - ..
License law dues not apply an owner of properly who bullas or Merton,
, seimproves
' .. and.wtmas.for such.pmjects with a communists) licensed pursnnnf m. me..
.._.. _ -2 04 -^-UNDERFLOOR"FRAME'—-- ---- - -- - ---'
Contractors-
lamp,and, l Sec
❑ 1 am exempt under See. _, B & P C for this rcasnn
205 - UNDERFLOOR'INSULATION
c -
Owner {��NS�TION
301 - ROUGH PLUMBING
W IdKER'S 1P DECLARATION
302 - TUB & OR SHOWER
I hereby afrm under penalty oury one of the following decimations:
303 - ROUGH MECHANICAL
0 I have end will maintain a'Ccni(cavc of Consent m self murne for wader's
3 04 - ROUGH ELECTRICAL
Compensation, as provided for by Section 3700 of the Labor -Code. for the
3 05 FRAME
_ performance or the work for which this permit is issued.
—
EII hay and will maintain Walk Insurance.er's Compensation Insurance. re
, quited by Section
306 - HOEDOWNS
37W of she Labnr'CnJa for fire performance of the work for which this permit is
307 - INSULATION
issued. My Worker's Compensation 1 summe causer and Policy number ax:
308'- :, SHEETROCK'
c t t tt • f I. 1 '.PolicyNoA
1'iCERTIFICATIONOFMEMPTIONFROMWORKERS',-- -
L -a x3O9` .�aEXTERTOR•ILATHv,,
„}
COMPENSATION, INSURANCE -
.. -. .. ..,
_... -... ..-.-,—
-310 - INTER -TOR ---LATH--
- rGsis,ccuanmmdnothauoflose dithe pc,air isforonehundreddollars
311 -' SCRATCH COAT
'If.nlfnexx.l .,
_.
-.,_,,. ...- ., _:.- _.... ..
313 --ROOF -NAIL,...,.. t, ....,..-
I- car y,that n th perfor on110111 w k tot wh¢h 'his perm t' issued, 1
-
he plYanyyer» nun nleco asubjectf m wit
501 - FINAL ELECTRICAli ENERGY
c penxIh fell 4 r_31< Looe
APPppI MG
502. -_.FINAL PLUMBING.. ENERGY
. cant L '4
NOgpE IUAPPLICA It after making the Certificate f Exemption,you should'
, _ - ...
503 - FINAL MECHANICAL ENERGY _
�bac nes comply the worker's Compensation provisionsofbe deeabormed Code, mint'
(onhwim comply with such provisions or this permit shell be deemed revoked.
504 — FINAL BUILDING ENERGY
- CONSTRUCTION LENDING AGENCY
505 - FINAL ELECTRICAL `
I hereby tillism that the t a commucn lending agency for the performance
tiu
4
506 - GAS TEST
of the work Tor which rots parmieissued (see. 3097, Ci, C.)
Under•, Name.. ._._.. _._...... ....._...._..,._
507 - FINAL PLUMBING _......_.__._._
507
Lenders Address
,1
FINAL MECHANICAL "
cenify mut I have read this application and slate thus the N. information is
Come,. I agree to comply with all city and county ordinances, and state laws relating
5 0 - NAL GRADE
to building constmerio, and hereby authorize' representatives ofthis city to enter upon
510 - NAL P G
the above-mentioned property for inspection purposes.
(Wei agree tessavq indemnify and keep haffnless the City of Cupemnoagainsf
51 - NAL B RKSliabi
and which may in any way seems against said
' Cityli. comequencesof the grnaing of this persoms.nses
q �
' APPLICANI'UNDERS'rANDS AND WILL CO LY WITH ACL NoN-POINT
W
Issued by; Dale
SO IRC ULAT ^"2 •
L.7%,igrainum of Applicxa ntrector I I Bgm .,,
Re -roofs
HA RDOU RIALS DISCLOSURE `
Will ihepplc tuft butldmg cupantstortohaome earardoux treterW
TYPe Of Roof - -
as de0nea by th C penin Municipal Code Chapter9 12 d theHealth and Safety
.Cod Scman 25532m
f ,1': 1+�••t-it,
iia i',f it tt ,
7f 1
ares XN%
"
t,'li'i s5
All roofs shall be inspected prior,[o any roofing material, being installed.
will tire or future building ocersionst use aqu porat or ch ice, which
If a roof is installed without first obtaining an inspection, I'agree to llemove
c f hazardous mrconmmmamv as defined by the Ba Area Air uhly Management
y
District?inspection.comply
�,
all new materials for Applicant,understands and will coin 1 with
. _
°Ye �
• 'al] non- oint source re ulations:.
sot lati s
I have fund the hazardous =[crisis requirements nit r Chapter'6.95 of the
C 1 fo n a Health & Safety Cale, Sections 25505, 25533 and 25534. 1 understood that
if the building docs not currently have a tematvthus if is my responsibility to notify the-
a'etipem of fhercquircmcros which must he mn prior m iauance oto Cenifcom of
07W
Applicant Date
-caner
__Signature„o-f -,.., _-, -. _
All roof coverings to be Class "B” or better
or aumodxd eg t Date
.:... .. .... .. OFFICE ....,....
�O
O
z
a
a
U
Cyry OF
CONIRNCTOR L`TOWTION:
BUnDWODr.F7SrOv�O pF
BUMDING ADDRESS:
FLRKT NO.
10550 WHITNEY WY
02080149
FTYM'& SHEILA DOLEZAL
aP>U08/2672002
PHONLs:
SANrCAR.Y NO, OOXML N0.
-z. AR4';1TTL•CTIENGD+'F.ER: ✓;
AUD.DNO PkjtMn• 6Y'FO
ELDG ELECT PLUMB MECH
:J LJ L:�7
LICENSED CO.VT^JCTOR'S DECIARATTON
Job Description
l+rschy'elTumflttL antkrnsnimukrpmvisionsofCat,ter9lro(lvnenring
vithSeulim40ti0pulDivxn®SMdteBuxlnasardprafeSi{uesCt+ ,.dmy,.ensc
MASTER
BATH REMODEL
im full force >'_'sd effem.
VLT
Urenst Class L-1^, a
Dole Gmtrartnt
P.p.CHA-ucrs DECLARATION
5 1 understand my plans &01 be used as pAlic recur
Licensed Prdtta;innal
i 0WhF.R-B1JWER DECLARATION
y I hereby affm3 due I ons erempl from the Conurttor't Ittenw Low for file
1
fe",lowing ma5w. (Secdon 7431 5.8uidntss and Professionit Code; Any ciry or court'
$ 3 0 Q 0
Whitt requires o permi; tc,mrnr;t, alter. irsprnc, dernolisb. or rega5r cny suucmrr.
prior roitsissunn= also mquirmftappliern,fasuehpernal°61eas4nedrmientent
- - -
,36§3,$�Li--fIPQ@rea
Valuation
Ihalhe(S,liusrird pUGaartrNdre[so,visicncol daCn,•rsalalrl.,:enseLe.'(Chtprcc4
(COenrLescap wSh Saetfom4%1W)off)it•isiat; of the Ruainenand P.pfgs-sans Cr.*j
w drat he it excutp: fti rmm 61d the basis for r1w dle_tol r-mrtiuri. Argy vial.606
s 4
ofie Iva ML5by umy appbnnt furs path suN„„cots rhe uppliarl l0aci+•il penalry
of um mcrc Cham owSaadmd &Tlfus ra.910).
101 AI'NVN°}LtJ OETATI ON
Occupancy Type
G 4 w rmw of the property, ur my mployeas with wpecs u ihcirsdaY-compensation,
102
- PIERS
wili'do d:c uxuk, and dr anurum 1t an inunded ew ulfesed fur rale (Sec. 7PI4,
Dmsroas and Profervimts Cd&: The h
Co orror's LirtrSe Law dens ta;a apply to an
103
- LIFER Required Inspections
p
owner orpmperty V1'ho bends or imnmiti, thereon, end who dxs well wok himstU
0.4
]s n
- RE13AR
a shrougb Hs own ea+ptuyee*. provided dint sorb improv anent; arc nog intended ov
offered tee safe, it. hawe.er, the buildng ce irnpiospmerl is sum -wldan ane year of
105
- ANCHOR BOLTS -
cunplCUun, ft owner•loulAr will firer Or bmden ad proving din he did tint build or
ICnprovc fur paipm o(sni”
106
- SEWER & WATER
'Tj 4 as oatxr of the propeny, am cyclusi+elycoeuacdeg with Icter-sedtcrnU=ors to
202
- UNDERFLOOR PLUMBING -
comiruct Jwppm�era (Se_. 7044, Dusinrss and P.•oiecscuas Coda:) The Cenan,:rxx
Liocdee Low irmpmHs
2 03
- UNDERFLOOR MECHANICAL
ddxs nor apply to an owner of prnrersp oho buiSis or 1.1sCo4
and. when eorSnack far such prajcru with u coctrartrAs) bcertsea) pursuant ea rte
204
- UNDERFLOOR FRAME -
Con"'Mur's Llrxnse Loy,
0 f ,a exempt U.&r See. , B & P C fur this reason
205
- UNDERFLOOR I NSUTAT I ON
�p -L
°ti-rtcc �ORI�S9TT0NbECLAftATIOV�7`�'`
301
- ROUGH PLUMBING
302
- TUB & OR SHOWER
I hereby orflum under pcnalry orpspm one of rhe following datlmdotm
303
- ROUGH MECHANICAL
el 1 hem ar,d .111 mitinmin a Cerirficate of Ccauem to s317-misu,-e for-wnria,'r
304
- ROUGH ELECTRICAL
Cumpettsatiot , as pr vl&d for by Section VW of the Labor Code, for dre
305
- FR
perdrnlance of ilio work lar wvidt this prmrit is earned.
-AME
I3 t hnva and will ntaintaEa t4Qvku'r Cumpen&rlion iNu==. as rmqUimJ in, Section
306
- HOLDOWNS
?10 of dx Labor Cate, for the perfortranot of the work ret wh5ch Allis pern6 6
307
- INSULATION
,led. My Vkrkda Cumpensadm (munutoe+-Arria and Policy nwher arc
3 0 8
- SHEETROCK - - -
C,urier; Poky No„
Cr --R ,CAAON OF 0(F-AfMON FROM WORKERS'
t '' 309
,
-:'EXTERIOR LA'T`H•'
W.MPENSATMI; INSURANCE
310
-.-INTERIOR LATH
fn''.+ merion used net be completed if Phe 7rnesif is for one hundred dollars
311
- SCRATCH COAT
(sI N)) or las.)
313
- ROOF NAIL
- 1 cersi(t ihte ill tie peJ,`.or -e Or the r.UrY ern u'hieh .i oermh is iuuW, t
Shall and tmpCoy taty pene'n o any miner so of to beconm subkrt to die Workers'
501
- F I NAL ELECTRICAL ENERGY
corty�ir;ad0a '""°flif ".e
502
- FINAL PLUMBING ENERGY
Ap'3iclau
1;�E . APFLIC N -1t, "An mskfnl( ellis CMilicale of Exemption. )nn sb9uld
5 0 3
- FINAL NAL MECHAN I CAL ENERGY
b:e subxn to rhe Xrids 'a, tram pmolsiom of de Lobar Ce,ae. yoru tit
fur&mllth comply with "h pro%i%;o ns or tt>ir t:ermlt ,hon he dmated rv%vked.
504
- FINAL BUIL t,
DING ENERG Y
1] CONS-MUC-71710N LLIC 1190 AGT:YCY
505
- FINAL ELECTRICAL -
I hereby nfrlrm 0.21 Una is a . msuueil,x 1a41rrg Satuvy for du: Firhrrruance
fila' is issued
- GAS TEST
ern of tNc work which Cris permit 43m ;097, Civ. Cl
Lcnd�sNamr,
-506
-
507
- FINAL PLUMBING
Under s Address
j
508
FINAL MECHANICAL
1 cenifp that 1 have taro dais at;tlimlien and st=018 I
tdrat tht above itt(atrnatiUo u
d echoes, I egret 10 compyy with nit city r_7count
y=4 cy urd-uu;Kea =4 Size taws r_Ialiq
50
�
- NAL GRADE
W widibe °nrlsma:tj n. mrd hreby authante IeprGitalLll•Itl or this City to enter apoti
510
f1
_ NALP x j
l+ AL
tri ab. —m-ntioned ptapet;y for inspection purposes
`J
Cir (ue)heroern;a—indCurn7fyand keep hursnlessthe EryvfCuNrLnnagairun
51
- NAL RKS
✓5 Iiabi`itir, ju4menu, C*,Zs uad expenses which muy in al7v way accrue ro inst sold
Z
City in a nscgrzeeo of @c &roaring of tb6 p.re-L
" ,LDpLICA\itJiVij JtSTAXDS AND WILL C 0 YWNALI. %* -?OPhf
so R Ll.AB S.
Issued by
Date
Rei -roofs
t nanlr n(App!irs • erne
H DOU . ALS DISC1.ASURE
Will the applies; t at ruaar. bNjioe (==:;ani sate or handto hmnolp"s rtttcrial
T)Te of Roof
as defined by the Cupenita Municipul Cgde. Chgp.ar 4.1.2, oria the Health and Safely
Carle, S=ibn 25332(Wl
°Yct -
All roofs shall be inspected prior to any roofing material- being installed.
Will nerpplieamafurmcbuilding "upomuse equipmmrordevirawhxh
Ha roof is
installe&without Ctst obtaining an inspection, I agree to remove
emir bs tardou; air cruturrns:s3 e3 defined by rho Day Arca qtr• Quality h:+arrngrmem
District!
all new materials
for inspection. Applicant understands acid will comply with
"Y"
-III non -point Source regulations.
1 hne rad dre hnw us materials mquiuenrents under Circpter 5.95 of 6 -
California )lcalth & StAty Co9c.Stctimns iss ,155?J 2nd%S5A l undilmuld shat
if tCe btdld7np Ewes rare ermenrjy have R tecaur-ultra h Es my rnpvasiblllty to notIry she
acqupaot of uit rrquiremcnts witch rnrst he MCt pricy to isxaL a of a Ceni llm a of
°euf""`
Signature of
Applicant Date
_
All roof coverings to be CIass r`B'r or better
Vu-ifter or authorized a VIA 11,- Date
OFFICE
CITY OF CGlItox 'ERTTNO
BI CONTRACTOR INFORMATION:
trrt,ut;rc ut�tsPERMIT
BUILDING rtIMESS-
0 O ANCIIITELV1- rG 1;! R:
~ ui
rV i im
V
�7 LCEV.y'h'DCOt,TfHACTCR'y'OLC7,•+,HATION
zI brttby n61no thm I mn'ice=n,1 rinser prmiei=.%of Cb;ijv. t 9 Lconji:r--:ring
nt11t Sect:an 70W)of Lh icinn: 01'ehe Fhisjit. %end I'rufu;ixMCadt,.und my licm5e
r S_ :3 is in fell fMet and t t l_
o Ff J Lirr,,;lieClnis_
i 3 k Arlt_ (Cnr:-suctcr ---
ARC3117ECT' S 15ECLAR AllON
I undewtuud my phut s:hnll Ir: usnl m public rbcon.;
�ri--
1% p 9 Lirea;r„0 Profesaiunal
0M.'N 7t-MLOER DFICLAR.-MION
tFi = m r hcrrby nf,lfm that I out exempt Inan the Caltracterk 1 ocztre L&w for I:ID
G 1 Q follo,&ms tz-4s6ct. r5tclioa Itr IS. 11minest and Pf Mims Ccde, Any Coy or cc -,My
r = n$ieh requ=& it perlu:l to cmbiru_ , n1wr, itnplinwe. dermli h. air repair any ttmcnite
-°�l•3^ paicsrwt'Ici,tei.?n+
as:e.alyam
ires:applKantmr>1KOpermfik
iStaneiEnedSlittemnl
e
Ils�l hij'u^_IiaYr;it!3 [nteaV✓1gwrF2 p, .:Aacina ul• the C'nnlrJ:lcfa License Luta• ((:h�:er 0
-kamt717x6gw;Eh,tecrhu :: .1) or Divicine 3 of the Bu:inee attd ('rptuvnns Cade)
or IGtr he ifexdtnpt thief Icon --A tide by is for the alab'cd exelnj�!inn. Au), tiolution
of Seairot 7{131.$ by -ray rglpliaant for n trr=il Sabjauu Ill: upplictuu to a Oral penult;'
a Cut mat Than'hae.5undred 4611a.-; IS}Uel.
01, a; "ner or the pmpctty. as Iny enpla}'oee with ut-,ws as dtcir cumpt:nralinn.
will ;tri the tt.njn'. and the t_=,Arc it' aril IolcuGed Gr oBertd Par Ndu (SeF iC",
8utbsrsr bud P,rrfcsscans (,'*dc: The Cuntmemb License Lax does my 4 ply to an
owner M property Who hoild; Or itrpn?aL`t therVa.:wl Qw drts such WCs& hi:nddf
or r!eautfh ILL owa tlugec;• ;unaided lhm such impnwoniraa nm nta rtilended or
y Ter(•dYar rule. IL Wo 6,er, the RdIding or improwmer is sand niith91 ont ),ear of
complctwn, ajar owner-bulkl^snill hs- r ebarders ol'pro0 ig that he ad ani Wild aC
impravo rot y,'>17•t:e of aole.j.
D I, is Irwxttrs n, thr pmpe;n•, an : ii ttiirelycc-Iracti� wir!t INC sell Cattrti; to
coingrn7 lad^- Qm}at (Se:. 7044, &hum and Profen:ams Codt::) The CcmlrbcwT'-
" l,lccu. Lew dues woe apply to us tame: of prnperry wbD build; Or imI)to-vu lheiron,
.. - aril wfia oUniractt lot le e0=r:tWlpl1imGYA1 PaIsuant_ro the.
enquuct&A Ldcensc LzN-
n [ nue ecenyl e�da •Sec. _ �_ _, R R: P C for chin rntum
Oantr _• ' Del,
WORK-ER'S CQb1PENSATION. UECLIRATION
I h. r y uffma under pen ally -or.perjury ode,ctf,Ure falkneute dcelur-igw=
F � t
Ci 1 hair and 1a-il7 mumrun a Ccr iflace of 0.*isetir 10 self-4wit: fct• tvarter's
Comporzditrm, a prn+iidaed fmL•y Seetcm 1703 of the Lahro Cade. for the
- (rcrfori-, 7cce ni rhe wart for whi.h tlds perulit is issxd_
01 large and *111 molutain Worker*,;a• S
Worker*,; dot.--trtaslieri Icc,unrct, ns required bCction
371'.0of dte Ul:h v Codif , for the per.ronr wq:e of ilak tusk fu + IE6 lhz-s 07ih a
- _ isermd My W(10,crs Ca)lttper_e+dun IeeurtrAu'caia rnd Policy rintherore;
CTNTIFICATION•OF' ];'1'L41f'PIOY FrtO�[ tFC13tKl?HS'
CUMpr-NSATION LYSUHiA'Cf?
(t!t-a tcction neat an; It, turn- iwtn if rhopermh isfarnse bondrrd dnllars
f ] IflOj ur i-"n.l
1 -
- I mi fy tb a hi red petrvrizue 611fie, n):a•& for which this rem: i is issait+7, I
lli:sll." csnpay-tmy perskt in ray tn=t.w'so ns Lis�tetsnntc sub3cr1 to'thr, wct t
Cu471pQtl0liam Laws uS Critilirn:a;
AI>timlitaml _t. _
NLTVICE TO APp4.1C:AJaT rl, e31er h lVag rli3'C�clt;Cate ud �aeodSriSq, gait 3hc�ld
b-c6iit.suhjkct w the%VaSi:dt CompehiAl h praili4nnsadthe iAbcr Coday0U muss
C fcrthwhhttvnpry with 4r_ch ptaa•Ittons Or this pErolkshi ll Le dst7led rernkctl
_ Ot),\SMC; TION I,ENDWIO AOFNCY
il*r.by nfi, 121 that thffe is ncrMIM-Ale" lezi ittl: agely`y fci c-ts: perPorynanoe
C of It`.' ymk rot whfdi Meta pemtl a itsuatl f Sec:3097, Q,,. C.j
G. C Lender's Name •-- '
A r Lcndcr's Adthczs .—� - �.��
V 0 1 Certify dint 1Irae =d thix tY.phemiga q41 sate tibt the nt"e infonturicu Is
rni7ecl. I ngtte to q(tigly with ell coy and cr, ily orilinuntxs end sire [A•N"a m1wipR
�•. t; j m Irlild'rn8 gnttba-cinn. and ftlrGby autiinria ,rnsen;at *% M IHis city to emrr wpm
K "{,�l the abuve•menldtuccl property fpr itsrsnu parp)sn.,
p. 4 kW4 agree to u•r e. I"mnify autdl;�ep F.trn:_St ae the CilM
)' of Cuprnu against
CC- vl ImElitizi, jut!bmenls. tuts nal eapen;es which tnay In any uuy RNmE agaimsl said
V Z city im consepucnte c; Lite R -A11 tb of rhlt yntrih.
AM-1CANT !NZZRSTA-11DS_ :%I) NV LsMWlYWir3 ALLSON•?t]u.'T
$OZ1RLZ RFC -L 1AM0N5.
S )tiralc of A he in"Co
H.4YAft0OUs'MAi'LR!ALS DrycLtjstlRe
= 51911i�apflticaanifbC:at:L•ss5]itlg'not+:ppwwt�fut�l5rftatrJlehp7ntddsteatef�l
ap 0eLced Ip' rte f,Z:pttinp 7Unripcl Clde. CJirptts y.l and Um HeLth nqd Safely
Cct;ta Secrmn, 25,55:(a1y , . -
C:Ites ,}Ida, •,
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aVill lbr gipl"Irun; pt fu= ,whlch
z'n
mit 142mriloui air con ittanLl as'6ii1lika by -lite flay Aran Asa QuNily MaOagerrenl
District?
0Yn R>•o
(•huae read the hamrdl� m prin'nls req=irt -i"U�r CI r.;' E.95 M tSc
Gtlifurnta l Iealtl).Y Sden' Cues, Y'ctians :5555; 2+533 cW ?5514.1 unNClsnzd that
• iy1410 kriildin_r,dn snulcun?aat• hyt; aIC:artt. Ihal r, is my respmil*iEllym nmffy the
o:cUpvq Qf Ibe relhirement3 •nt.::tl merest ht:md p6to issuance or a Ce10I.;T to of
fkCulranc}t. , t '.
!` (>:Y,t: n) tathnri7cd agC nlr- - .. Date
Mh.frr NO.
BLDG ELn: r
Job Description
ELECT UPGRADE --IN HOUSE USE ONLY
ORIGINAL 402080149
5q. Ft:.F1oorA,,Lea $300
3 5 98M214rulft I cu
1 U ti 1J Jdid Reeqquired Inspections '
304 - ROUGH ELECTRICAL
505 FINAL. ELECTRICAL"
\Q
XM"a T MD
PLUMB MUCH
I _:3 -1
/L y
Issued bye Date
Re -roofs
Type of Roof
All roofs shall. be inspected prior to any. roofing material -being installed.
U a roof is installed tislithout first obtaining an inspection; Pr�gree to remove
all new materials for inspection. Applicantunderstands and win comply with
all non -point source regulatibns,
Signature of A_ ppficant Date
All roof coverings to be Class "B" or better'
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