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CITY OF CUPERTINO
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BUILDING DIVISION PERM
;- CONTRACTOR INFORMATION:
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BUILDING ADDRESS:
S B I
PERMU ND' 06030134
10981 ACACIA
NAME:
PERKrT ISSUE DACE
IFR'S
HOMESTEAD RD LP
395 D
P ONE
SANrrARY N0. CONTROL NO.
(831)274 -2518
ARCHRECTYENCIN
BUILDING PERMR IN Po
'
REDO E.ER PLUMB NECH
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LICENSED CONTRACTORS DECLARATION
Job Description
1 busby aR Ibis 1 w Ixona A urde PMvhmns or CDapic 9 (cammsncint
with Sntkn 704) of Diridoa 3 of the Bazi an4 NoIculom Cade. And my H. I.
In full fore and e(rat Q G
REVISION- STRUCTURAL.THROUGHOUT
�L
Dare comrawr
ORIG PERMIT #05090180 —NO NEW PERMIT
ARC1Ir1ECTS DECLARATION -
1 on&nund my pWn alell tr urd as Nblk recoNa
Lk.0 d Pmfendond
OWNER-BUILDER DECLARATION
I hcmby anlm thw I aw eau M f oto the Conuanda Lion Ltn, for ft
falmv : mum. (S"tion 7031 .5. Bu inw ad Pmkadom Cam: Any city at county
ohkb req i,M a pomp w Consuuct, a , hnpni dcmol W, m mpwr any urw:wm
! prior 0 u muuce. Also nyu=thsapplkam fmsueh pormitw fk ad�trd ltllemL01
ca
Sq. Ft. Floor Area
Valuation $0
m„xilna dp m. lm h pman,ar4 a m r a ,.fa.pm9
(commettdn,; olm SCnion7000) of Mi Llimlof the BUimori Pmfeviom Cadcla
Oat be is eaemyl thmj na and Ne Wilt fa ft ,heed ouMiptlm My Nola km of
APN Number
Occupancy Type
SCalm 7831.5 by any appuem r «a pi nit athjeat we aPPUenl to a crJ p Miry of
na note thin fw Inmdtd mean MOB,
32602065. 0 0
❑1, ua of die pmpep. m Rg vopinm a vap u deU mle compevvmn.
Required Ins Inspections
pe
,ft. ,r kandmetwratmkammtenee dorofmm for ,ak(s .7w+.Botim.
am Pmresdvm code: 77c como.,we, Limtae Lao doea eat appy W an arrtcr ar
pmpw, ,on Wilts n imraeraa Neem. and who does ni oath him-Jr m lhmuib hit
awaopbym, pm M d that sti moprurrmau e<not imeni naffed for sale B.
hoverer. the holm" Ynpm. Ant k mid.shin am 7aar of comPkuan. me--
boldery the Ih bmdrn M rimn, dot n dW on mw or inprme for PwWC of
Ask I.
❑ 1. u avner of do PmpertY. w ndumo y con"ctiej oiN Ik®cd Cmnaannt in
conatmn Ih project (See 7 . Bamn mAl Pndwdan Code) Tho coot, ara V
. L� dm on appy to an owner of Property oho bu ldt or impm¢s theteaa amt.
\iN
oho Conutufn so0 proemadm acanawtor(s) Bmncd Purmant to do Corms s
\` \J
Lat. Lai
IamuemNwtdmsma .BAPCI.IMsreuon
Due
WORKERS COMPENSATION DECLARATION
I bceby ani. Mode, pemhy ar Pnhoy woe of de follmdnr drd MtM�
I hiw<aM rIU mdataVa a Cmifiote of Cwcne to coif -Tomes fat WortefsCaopeo-
u = u prwimd far by SeCBaR 37170 of the Mbar Code, far df pedotmr d do
o for obich 0u pani, a mums
❑ 1 bare and o fi mdeaiL W , CmopMotatin I.. u trydrd by Scaian
'
37 ame I-Mor Colo, fat me ped. Ntlte.mh fa oMcb dda perch u Hmcd.
My Workees Cmtpewdm Inmaac rimier and Polky mAoftt _ r
'are'
Carrie PNky Noe:
„'" CER7'IFIG OF E%EMPTION FROM WORKERS'
COMPENSATION INSURANCE
mtis calm recd nm ba compIc" Vibe pmmb u fur Coe hmmoo mWn (SI Wl
or ss)
I¢Nh mat In WC purom.oftm ooh for o WoepmoirkiMi 19.11 Ma
.
cmpby ar0'oersun In any manncrm u to h .bjecl to Ne Warkrf Cdopemulon
� Of CdifamlL Doc
Applkmt
NOTICE TO APPLICANT: If. afMr mahinr Ihu CMOBAaa: of E Plion. Yon mould
boo subjca W to wohLa Compenadoe pm.wom of dte IAbv Code yoo mm
fonhoiW comply olds such pro sIom or mu permit coal be domed mated
CONSTRUCTION LENDING AGENCY
1hor.1off tha there Va a) fn me pwfarma,tco or
d, t,ti(S 3 .Gil.
� do wmh la aNch INS pcmit E istcd (5¢ 709'1, Clr. C)
Lendeh Admen
�
D I ¢ y Nat I Mrs tud m, "Iiaion and tic mu We aho.e iNarmadm is
conca 1 aprm W Comply vim dl city and coaaty ordi� ad suk loot Miasing W
Nloml COnm M. and hcmby mtbonn tcpteantwl.et of this city W Cmcr uptn do
,
ate - mwuicrad propcny for impaCdan Pure=&
L (WS) Kos to a c. idamdfy and trsp barmkaa do City a Cu1L'nim ataintt
IiaNjiLi,,jad,.MC= ad eapeua which may Nary way amoc atalnm said City
APPLI UNDERSTANDS AND WILL COMPLY WrTH ALL NON-POINT
Issued by: Date
DURC�� UG.ATIOfiS
- Re -roofs
Type Of Roof
- lF 7NR_ )/O(,
Sitmtue of Appl A E Oise
a
HAZARDOUS MATERIALS DISCLOSURE
ar handle hKOMA dy
rawm buUdwjc,
WNdoapCup
amitare
!
u defkcd OY Nc Cupenim Mumcpal Cade, ma p¢, 9.1; and the Holm and Wmy
Mda
'
Srndm 25537417
Cy.
All roofs shall he inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Mil dw appl n ratan limWine ocoapant ac m,%opmcot or dcrim ohkn
emit W uni m air cvnuminavu a mflft,i by me Bay Aru Air Qu11ly &4M&V oent
all new materials for inspection.
Da tt
❑Yo No
IU. Wdo hanrd Maiorlaltt mncnuu ,CWPa�6.95ofOCCalifm-
tua H.A" & Safety Codc. S vota 25505.25533 cW2553d.1 wdatmi NaifNc Wide{
QooA rnmtnly W.a a scum, aw h u my tupon Wit' W mdry Ik u¢upat aft
mR MoAttcmctPWinoamoeor.Cmifiata
Signature of Applicant Date
"����
All roof coverings to be Class "B" or better
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Mlcr n aadlar]ld apCm Da1C