05100130 CITY OF CUPERTINO a 'm"' .�e`c'
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BUILDING DIVISION PERMIT F,ORMATION,
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DIIDING ADDRESS: ELMENGARD INC. �RM�NO'05100130
10410 ANN ARBOR AV
^''NER'S NAME: PERhOT LSUB DATE
JOHN TRACY 176 SECOND ST.
NF SA ARY NO, CONTROL NO.
(650) 948-3613
ARCHMECVENCINEER: BUILDING PERMR INFO
BLDG FIFCT PWMB NEt73
Too I.3c&NsmcorrlRAc3oRSDEcuRAnoN Job Description
1 kacby inm tbu I w ji—i.akr pm j Wm a Cb.ptcr 9(atmmmtclnt
Itb S«uov 70701 aDiiskn 3 of tet Buain avdN IcLskm Code.and my..."..0
mrwlf.aadcnca REVISION ORIG PERMIT#05060042
LkeataChsa La.t VAULT KTCHN CEILING AND CHANGE EXT SIDING
it Dore ARCH ITECITD�FL'I ArION ON HALF -OF HOUSE
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OWNER-BUILDER DECLARATION
5 1 hucby aRra w.t I.m..Pt from Ne Cmbwora Ilan.Lar I.the
dWo inG ,...tL(Sevum 7031.5.BaWeaa and Pmfessaaa Code:My city«mumy
3$ which tcqukm.permit b cmwtct Wer.m�K•m ctlL k«mPak ny at=t.
iy prbrii,iuissuuvx.almrcquimthe MTiomf«mclp i'Wfikaalprcdaurmrnl Ft.Floor Area Valuation
ss< wn m u 1{ansd pvsmmL ICL Nc pmiilmn ache Cawatora IJ¢�Vw(Gap«9 Sq
y�F$ (c .nd.{with Sed.7000)a Dividm 3 a the Brmrcaark Pmfc>nom Codc)« $87
[ _ wac k is eaemp w d.artd tk bub fa rite aUgt matpdm My Awat4m a
Scam 7031.5byarty"plwnt f«.pewit amjtm me.pgBvn b.ciHl pmhy a APN Number Occupancy Type
tut nsme thaw Bw hmdrtd dk,h ($5084 .
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wBmmeew« ,new„wameo-.wwaae«a �rIXa. fs«. ou,e�«n Required Inspections
ark p r,,a jom Cade The C.a=c a I k®e Law don n«apply,ban awns a pe
pmpeny rho buBda«impmea themun.and wetdou arch w hkruffa dtrvellh Na
bm employee..cli.1. tt,aoch hepo.1d arz n«hneudcd *a rIX ase If.
howuv,we ad ib t m topowonu h mad wthN ate year amaplmol the ocm a
hvlda wN base the havdm a pmNnt WL le dk td hula a heprore f«porpe a
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t awma Of wePmpn.w aduaas cmuuint weh Ilattad ansctm n ,/
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WORII COMPFNSAMW DECLARATM
J� Ibr+rby Ntrma er pvWryapa}my meath(an.ktt
�� IN+e oar will for by . ..3370D a Coram b aU-Ins.rtr«WatdsCavprm-
ativrc u pawihk f«lry Secuvo]7110 a we Lab«Code,f«am prforman¢a tet
wort f«which wia parch Law
❑I ba,e M in m.lnaiv W«tr!a Compemulan u tegwrtd by Section .
Md the Labs Code,r«dr pctfarmaetn of we wart f«wbkb wit N.4 h lured
My Wae%cmpests.um ias mrw and Pomy ntn art:
Cartb: Polley N04
CERTIFICATE OF EXEMPnON FROM WORKERS
COMPENSATION INSURANCE
Cl7dsamim¢d ort becmtPletld if the rmhbf«om bmtwNcd aoOua(t 1001
«lea)
1 I.t�N tet Pafmm.n or w a which W s p t h Iav(ed,1 abVl na
wpby arty pesmnin urym crm b more mbjccAntarta Cnm
Iters of Califarvia D.
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NOTICE TO APPLICANT:B..(br mAng this CcNawraf Ea C yet ahau6
Oecorve a..'b W WakrYs Coe tet p MiiL"a(we Leh rCode yet mtm
�O raww;wmmpy wiwaeen poriilam awu permhalwlma«mw mand.
z CONMUC1710N I.ENDDIG AGENCY
[-.4 1 heaby affoa that,there It.mmuuctm kownt.pwy r«we perf«mvta of .
a > tet work r«whkh thio parch Is awed(Sc 3(197,CN.C)
es Nave '
a7 z Irndeh Addrta
I asufy wu I ho e r tNa wpiO oo ark arca tbu tit.boa iaottnaum is
W 0 coarca.I mra W m Ply with all city am c Ly adirus¢a and state lam rcluint b
Vh Wlot cmammivn,WM.by mtbave rtprmentathaaatbu dty menta wpm Nc .
rte abmc umaW papny I.hopevm pnryoas .
(Wo.tore m aI iry ante ke humka the City a C.penivu taunt
()z '.bilitb.}WtT/ I;1-
It tv NLp�may bt my my.cmte apaimtsak City
APPLICANT A SAND WILL COMPLY Wrrll All ON- INT Issued by: Date
SOURCE REG
11 Z° 0
Re-roofs 6kL
/—J ✓7 ci
SIIInaLWea ppl' I 06r.
US MATERIALS DISCLOSURE Type of Roof
WIBne.ppliam p..,.,.hdldmp oaapmLRorc IXh.nAo h.urdmsma¢nal
u&EM d by Ne CupnleoMurtin�l cat.Chapter 9.12.utd the HdN wk Safety
vle.Stalm 255324)? (�anp/o All roofs shall be inspected prior to any roofing material being installed.
❑Y
If a roof is installed without firs[obtaining an inspection,I agree to remove
wtB we.pplkmt a rut=beilmnt=tipa t b equipmtmt a levia¢a whkh
/emit wxdm,air mvmtunams aa O:ri t by to Bay Arta Alf Qtalhma
y Mpmtw all new materials for inspection.
jj Diauint
E]Y.
I here mid .Isrtrpthatxvaatbdm Chem E95aOt Calif«.
nlalkalw&Safdy .2SSll ek2153s.l akcntmdtha Btk hitlht
dao ort c ,nly a wu h is my teapmdWit,b t fy the ado
myotrtmca/s F Pd«bmvst¢M.0 0 Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner a mtnaved ate ham. .