05060042 CITY OF CUPERTINO rRG' �TC*�a.H.a �+�cY �t 'y��,��'
BUILDING DIVISION PERT Y G®NTRACTORINFO.RMATIQN
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BUILDING ADDRESS: """0 5 0 6 0 0 4 2
1041n ANN APRr)P AIT17i
OWNER'S NAME: PERMIT ISSUE DATE
1101111, JO
E; SANITARY NO. CONTIROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG EIECr PLUMB MECH
ZZ 0 0
O p LICENSED CONTRACTOR'S DECLARATION Job Description
F 1 hucby.form Wu I w lii:c c mW«poe4lot a Chaper 9(mmmcn<ini P
MN Se<dm 7")of Dir Joftho Buaircis and ProfcW=Code,and my liCenao i.
n WrWlraaandur« ADD 448 ' —LIV. SPACE/GARAGE-301 '
jq: o nWcl..a cCmt� CONVERT LIV. SPACE T [[[
ARCH11kuso DECLARATION®
d vanJmypauCHIlhc u ECL R aced ADD GREAT RM & REMOD
`D IJcrnacd PntreWoml
OWNER-BUILDER DECLARATION
�nC follows ricuvan1 botchy,(SeNunffirm a701.t BuLnmaa and Pmfe na Code My¢y«Law fmuor uy FE19 _ 2006
S wbl<h I Oim,.p,mu w cmervcl,aM.Imprare,dcmrYirh,«nfia i any W'r<lum
zi fri«In jt,i"..ako mryWma Ne.ppliew f«Suchr itw OkauLnd Nkmml
< Nat heis1a dputun
nntNcpimriaionaartbeCtmux
cine. . a.chap<r9 Sq.Ft. Floor Area ation
E�G (cammatuimt wlNSeclien 7000)d Drc n S of Ne Bu,i«a,and Pmfrslona Code)«
$ Nu ha r,tamp Nemfmm ami Ne bola in,Na alkgcd a Pdoo.Amy Nolamn of fflkrlftC 200000
SauwnML5by.nyapplicant for.ptmnawijeMtha.pOinntonA l]Pawlyof APN Number cupancyType
net mac Nam B,e hondmd dollen(5-50M.
Ql,umwmer of Ne popr+ty,«my unpb3R.wW wgau Ne"v aoka penullo,ti
mumN w«1 and ha u na n«m nda«nu�adr«acts . oN.B a� Required Inspections
ad Prufu i.Cade The Contncbrt Lhvt><Wm dW apply W an awrer of q P
pn "who Wilda«import,LbomL anIwhodma work hirueu«Wwgb Kit
twoamplayca,pry 0.1 anch impro,emenu ua matlmendcd«offm for.aim B.
bawler.Ne bWunp«impoK umWwi0unourYesof,nrn'kiogNeowna-
buRder wilt bare the b,mdcn of ProrinY Nat h did rot bWk«impure I.purpose of -
uk.1
El 1,a,a of tte pvpny,am a in,twiy<wuaning with limuad cenua<mn W
aasswm Ne pmjeaSOtm, -- su Coe:)The Comk .LI-
e❑ert.lea
asr
lawdtnol wbabaiiis v.wImruPmW,Nte NCmu.n,and.
whocnucl.f«
no 'aw.
mapd N .06PCf
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WORKERS PF1lSATION DECLARATON
1 Ymby affirmanile tywPerj«y on,of Nm rwlm.Ng aau.,Wate
I ha.cadw0iinai acwirr mor Con.cu to, f-m.va f«W«trr's comp
vdm.as pm,idd for by Stion 3770 of N,lab«Code,I.Na puformarae Of Ne
work for whkh Ni,fa hUWood.
❑1 b.,e ant,w fi main Wn w«tri.Compauatian Imuan¢..rtgWrN by Scrtim
3700 of Na lams,Com.for N<pufamoanuc of the work W wbich Nu pL itia isrueA.
My Water,C.'rutatim Irtmrvax oMa arta Polley Dumber are:
Cancer: Parry Na:
CEILIIRCATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(rnl.acdm rcW 4c pl d'JNe purou uf«,arc huntedmWn(S I00)
m ku7
I anify Nal in N<prro ant of work f«which W, It 4Ia«W.I,ball n«
cmplgatry p<m in an m u, uwbcnornO ubjem Wt Warks Cmn 'on
Law of Wlf tD
Appliam ---
NOTICE TO MPLIGNT:IL a .n
fkr m g 01,CcNB a of Eaemptim.you.haunt.
betWme.ubjen W Nc WorkerY tmtion Pniniwu W Na Laborcdc you mun
,Jz rmnhwiNcomply riN such Pm' urn«NY permit ahLl bedmrcd rc,mkcd.
'7,C) C uc ONE DINGAGENCY
N.tNmice. (S5nnkMinL.Larc.Y r«Ne ppfa,martu ur
Or. .� ft wrrrfor whkhNU penult V WuoAcd(Sas 091,Civ.CJ
W Q land<r3N.
7 X mower.A�
U O 1 miry Nal I nave mad this appliculan and.wa Nu t Wore information O
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coI =W amnpy with LI w cou
I dty. nty onfi uvwe hWli
A aw r .S is
building co,uuucvm.ud he"y au i Mr, . wima ar this City W tura upm Nc
CL EFPLICA�
(W.) ole-n ;« ik=Ph3(4,j 9mo b nl arid kKP xy nn ar ,i iy Of fJIP sidLNItie.jwLmeW, ea whirlmayNanYwY.<aueaµnuuidCityUz uW«^TMNe 0 or i,fctmiL UND ST rD AND WILL COMPLY WITN NO -POINT Issued by: Date
SOURCE ftEGU ON - — -ZZ D/-
j _ .Re-roofs C�
Sipnaw,ear IianuC nvaamr Due
HAv,RDoJJ33 MArml,usDlsa.anlaE Type of Roof
WIO Ne+Ppiamt«ions na cc,c.cup'.
u 'nave L W t1c ha'vrdau,material
u defbrd by Ne CupeNno(unklTW Code.Chapu 9.12 aw Ne IkLN ani SLUT
Coolie.Section M532(.)? All roofs shall be inspected prior to any roofing material being installed.
C1 Yt
Will Ne applicant Atom a bWlding by the D tomit Air Qu«JMU. whim
If a roof is installed without first obtaining an inspection,I agree to remove
w,rdam.Lr contaminants u dcrncd by the Bar Aura Ab OaLhr Man.gcmcN all new materials for inspection.
DwraP
❑Ya u�
I ha,c mai 5533 c5534.1 rvinJt95orNcGllfm-
NaIYaI'n aid 25505.2597 aw 25534.1undcrsr, Butiflbc 4dlding
ds,n«<wmml ha Nu¢V my r«pwvibility W 01Y Nc t of Na
t,ulmmcruw h Ic Ips«ni..nan<c of.cadr or oa< - Signature of Applicant Dale
d$`
own No . D W All roof coverings to be Class"B"or better