05120002 CITY OF CUPERTINO �✓ -+ .,4w,tres»e�4
BUILDING DIVISION PERMIT �;Z'6NTRACTO° RAINFURMATION
BUILDING ADDRESS: PERMIT NO.05120002
22655 ALCATLE, RD
RS NAME: PERMIT[ZOE DATE
MARIANIST PROVINCE OF THE U. S . . 12/16/2005
SANITARY NO. CONTROL NO.
ARCHITECf/FNGINEFR:
BUILDING PERMIT INFO
BLDG F1ELT PLUMB MECH
0 0 0
196
LICENSED CONTRACTOR'S DECLARATION Job Description
I lucby.f i.toot 1 sur ucet tca oMcr Prot'IOmr or ChsPlcr 9 rcommmcins
N Src,im]000)of D'rvW o0 3a&Buiw tuns PW feslm.Codc..N my liccnc 4
m(unforce
uMeOa REVISION--REPLACE CEIL BEAMS IN ATTIC
Licmhoassscmm�cmr NO NEW PERMIT ISSUED/ORIG. #05090221
3 ARCHrIF=S DECLARATION
I urdnwN my Plums WWI h toed u public mccra.
J U
S0� IJ
ccnvA Rufcmaul
OW NER-BUILDER DECLARATION
a� 1 hmhy Arlin,thou I sm.crop,from Is,Conux,o(r limn Taw for Nc
00 folbwing muter,(Srcuon 703 M.Butvr4.Ana Pm0.svom Code:My city or county
which oui.im_t."it to cnn.uun,.1w.nnimum dcmulith.«WlWr any n,uOI. .
_z> primmitsctmcu .usu require Tit.pplinrur r«au'bl�^hmnk.u�rca uucmcm
F < thnhl.0«mcdSq.Ft. Floor Area Valuation
r,�$ (cot be,..t wiNSeNoo70(pl the tivuimJ of llctzol andboo."rrlsoek)« $0
Iw he u.Trop,Niscfrom trw Ne I,.v.I.Ife weim.anPdon Mr tid,n�m or
Semon 70315 by mY•pplituInt for a permit subjects the Applicnu W•civil pvumlY of APN Number Occupancy Type
trot mm Nan Rte hu dred dollAn WW5
❑1.u owner MJie pmpmY•a mY cropluycu wnb wAte.u rhn hole compvts.Jon,
willdo Jc woh,sM Wcmunortuw,imerdrd«onaWr«uk(Sec.W iti nerof
,,,d Pmfeulom cede Tee em,r.moft LianW".ane.m,•pdr n•n n,,,,m M Required Inspections
progenywboss,mo«impure.ti, mm,,c wbo doutu«h wart booffccr thmuth m.
own=m.thec.ilding ,impOd such impmtemcotsinone year
dmpicom fnu -
boveru,theurnIts, urmi otement I.sold withinoneyear M mmmcfar theposc of /
uicder will hs.e Ne burden of Ro^hot tots h d'W va hallo a Mpro.e f«purpt¢M
0 I,a owrer M tit P=^WtY.•m csO]" y comOIc iS licenW amv.nm to
corauun tit pmjcm(Sec.7014,Boiwt.W Profeuiou Code:)Th Coev.m«'s U- �J
ceue Isw do.non spply W so owner of pmperty,who buiNs or imPmne,ha®u,sod.
wba cmuacu r«ouch mrjects with.comma(.)llmmd pmwun W be Comuctut.
Llcc=Icw.
0�l.m No Sri
und ,BkPC(«Wa
,;A27 -
WORKERs COMPENSATION DKLARAnON
t I bercby 911m uohr pcwlty M perjury oro of the follouint dalsu o wL -
Iharc.MwillmainWnacc,uir Wof ConxM to tcf-mtme for w« sComp=n.
.tiro,u provides fa by Saver)700 M Ih lobar Coo.fm Je pMarm.ae M the
wort for which thio Pamir I.istvc4
❑I bvc sob will m timson Worbal Comperwrim Inturmce,as rtyuird by$cction
37W of the I'6 Code,for the perform.oa of tit wort f«which this perMt Y Wood.
My Waked.Cm omiso.InP.oma.nd Polity nort,cr
Ctuma: Policy No:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSAnON INSURANCE
(TTLntecrim Rad rot h cwnpleed If the puma V f«ane huMrcd do0artu(SIIXI)
«lot)
1«Airy ths,w the pufam.4a of Jc wort f«were.this Permit V iauW.I.Edi oat
cmPthyM Persuniom mmucrhoumbcmme subja„o NC Watrn'C«npeuulm
L 017Calir •D
NOTICE NOTICE PLTCANr: f.a cr mating his CerJf..o.M Exemption,you thud
banm ubJ I,Ne Woha't Coropeoutbn corol 00 M the Iocbm Code,you man
�z faMwith y with tach P^vWon•or Nu pvmir NJI h a«mW mated.
Z� CONSnRUCnON LENDING AGENCY
�-.� Ihmby.M.Thu then u.rnnurOct.ladint.tcrey f«the prffarrn.M
fk i Ja watt for which dub permit U in«d(Sa.UP7,Civ.C.)
IcnticYs Name
z I<Medt Adareu
U O 1 errufy Jut I MW red this appliction tuna u.rc Ihu f.bocc inrvmtuJan u
�—' currcn.I tt r W comply with all city sod country ordirunxt and tore Int.resont W
0 bMdint con don,sM hmby.uthorlre tcPmsnu,Ire4 M,hs city W cora upon the
Ill ahorc-menvarcd proper,y r«iuprmim p«poWt
(Wc)arm W ate,indemnify sous trop bsomkas Itc Cly MCuparim,.l
L1, IlNilivu,luagmmu,rn .mo
uae.,, whits may I.my way socue.talul x.q City
U 2 in conrequsae M the Staving orthu permit -
APPLICANT UNDERSTANDS AND WILL COMPLY WrrN ALL NON-POINT Issued by: Date
s0 RE n /a 6 ✓ Re-roofs
Sjotalikof A,1IcsmVCmuacWr D.le
FIAZARDOUS MATERIALS DISCLOSURE Type of Roof
t0 f 1pp0ent«(inure ddlaiag occuPmtnort«budth husodmr rwcri.l
u defurs by Ih Cupemm Mumclpl Code,Cltpurr 9A2."yo,HeIN aM Safmy
Scmlon 25532(,)7 All roofs shall be inspected nor to an roofing material being installed.
❑vo ONa P� P Y B B
A Will ft pplWmt or forum building ocOu hot use cgWpmmt«MIc4 whkh If a roof is installed without first obtaining an inspection,I agree to remove
emit hsrallout air muumin.nts u de0md by tit Bay Ams Air O,Wity MsosI;c t all new materials for inspection.
D u n7
oYn. ❑Na
I bm mul Ih lu udow mucria4 m,uhnnO s urdcr Chtplcr 695 MJc Calirw.
nUHelth&S.fmyCodc.Sc:Jw 75505,23533 uu12553d.l inert dam itlh WiLdin
dee rot cur=mly laic.r^•.r thou 1,u my mqunJmlity m ruaufy the«eupsoa of the
coq 'hoombc priormrsmxcof.Cudfnnon Signature of Applicant Date
All roof coverings to be Class"B"or better
hotharixd.gen, D.W