05030014 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAMIRINVORMATION�:'
BUILDER
ING ADDRESS: PMIT o-0 55 0 3 0 014
0564 N BLANEY V
�- 'S NAME PERMIT UWE DATE
JON CROCKETT 08/05/2005
1 E SANITARY NO. CONTROL NO.
ARCHITECTIENGINEEdt: BUILDING PERMIT INFO
BLDG ELECT PWMB MECH
O O O
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LICENSED CONTRACTORS DECLARATION JobDescrition
or 1 baeby aRmt that I.m liaax0 under po imntu of chummy 9(rommeming P
lU� with Section 7000)of Dir.3.f de Buto.W Pm(rtrah.Code,atd mYlice—h
± „ inrmlrmaand u a ADD 617 ' --LIV/GARAGE 400 '
j tlz D.w Cha
F D.¢ CC
anon
mARCHITECTS DECL ON
I mnd 001 be used u pullie,
ra«d+
SU
eQ� Licentod Pm(eswrul
OWNER-BUILDER DECLARATION
qy�yr i 5 I hcrthy afRrm tb.t .m caempt from the Contract." Irfor the
`p following mamn.(Salim 701I 3 M.Basi a n!Pmfaabm Code:My ehY or county
5$ wbich mqulra.Root to cmArm,,9w,hnprme, oon. JL or.*r my+vuctum
Pnor m Rs Lau.rtce..ua tryuire ihe+pplium fort opmnitlo ftle.si9no,i atement
that no h llrrard Pasant to u ren.isi .d tho C.—'-u —Law(Cn.p�9 Sq. Ft. Floor Area Valuation
E�$ (commortcing witb Sralm 7000).f Di,kian3 athe Bu.irrai and Prorcasiotu Coac)« $132266
— that he b e pt thra(mrn ark the b.,:•r«the Orzoil aemplm"Any v L&L oo a
section 7W L3 by my applicant Lor.permit mbjecu the.pptirnt to.CiQ Poruny a APN Number Occupancy Type
not more tom Ow handred dolha Ww5
❑1.u owrcr of toe popvty,a mY wpro,.."wW u tltetr tote campvu.daq
will k) nma
uwo . tees 1.not inrntded«oBerrdroraate(Sm.7UN,Btoti. Required actions
anti P r ant Code The Coou l Looe Law aoa not apply W an awrcer of q P
properly who bonds or imptmes dtucaa,ana whoaresateh wvk hl covaXwthroog),hu
owm empby«s,Prwkea that Wit irop' mu.rt not intugea or ofresM fm ole.If.
bvwew.ae building ornnpocemrnn h aold within oto year ar mmPkdm,the owoer-
WiWor will bate a baNut of proving data oc did rot beDd or hnpraw for pvpna of
aka,
i le-7 tLuwxr of)=(Srn;.70 weulmrvdY ronuulnL withlia a,cootu . m
corovua cr pojem(Sec.nano Buslrta and Py wncl«u Cade:)The Cmtr coon.Li- /
roueI tr douno.ppro an an owner of proWY wbo�Id+arImpnKa demo.ma /y``-(\/`
who.Law.f«.«b pojau Nth.cowatar(a)Batuea purwam m the Cmtmots l
Liana law. /�
Qlam puts/q.1�See BAPCf«thhrgaoo /
WORKERS COMPENSATION DECUBATION
' lheteby.Inrm under pvWty of pajmyarc a<the falbwing dNuvions V '
as arM wBl forty n.CemlBate nrfomentr Door,for foroff. ofth-
u Pr r li toi !pt oti Saban 7700 0(Ue I�nor Cade,far toe perfmmart¢of the G
for which this pmnit 4luuN. ,
131htt .m,1 will romnam Worker's Compeosarion Iswuarta,u"oma by Scctim
7700 of the Mbar Cad:,for the perfamuna of that w«k fo which this avoir h ia«d.
MYWorkds Compon inion Wmarrs onkr mtd Pollry number uc
I
cmier: Palley No.:
\ CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
rlbhs aced ttotbe canpkrd Bth pooh h for me hundriA don•^($100)
1¢niry that In the paform.xe of the work for which tnu permit it,iaRed.I shall not
empty M'Poon In mrmmnc n Y toirmme subjret to the Workers'Cmtpcowlm
Ito of Gllfordy Due f:/r .t'.
NOTICE TO APPLICANT:If.after making this CeNrtc.te or E pdm,You sI.W
become W bjo t to the Worku'.Coaitcttation pm ooa N the Lab«Code,you into
.0 Z. forthwith romplY wink s«a pmrisiotu«wa pe.ir snarl no domed tewkM.
Z O CONSTRUCTION LENDING AGENCY
'e. Iletaby alt.that there h.mnwuaxn loodinL•Lemy la t pMormana of
W > the wort I.whim Nis permit h laud(Sec.7097,Ci,C.)
Qlmdrfs Note
a Z I�taeY.Arlo.
U0 I a JY that I hate road dda appliotim and state dun the Ware inromadan la
T, caves I.Lta W cooply with all clty atN'c tory mdin.•^•mcJ state IM roW in$m
O Wilding conmu on,and hereby nnhome repr=rtali. or this city to mw upon tin
fA .bow-mmtico"property for Impaction puryaet
(We)agree m art,indonN(y and bmp barmloa Ne City of Cupertido.LUM
Co) O.bllitiea,judgmenu.emu utd e.pemea winch nay In my way roue KaloaL aid City
U � In 9 Nf a D g STANDS AND WILL COMPLY WITH ALL ON-POINT Issued by: Date —,{'---
$ 6�
WRC TIONS71RE_ c s"�� Re-roofs 6 a4Si edf Appllaru/C -- Due1fAU$MATERIALS DISCLOSURE Type of Roof
W01 tle.pplianw bWlding accorator atort m b.Mk hanrdpn materialford by Ne Cupvttiel Code.Chapo 9.11.arq the Halth mAWoy All roofs shall be inspected prior to any roofing material being installed.
❑Ye uwtu de applluos building«culam me rGalptnw«darlpu wbicnIf a roof is installed without first obtaining an inspection,I agree to remove
a rima by u Bar Arra Air Qwitr Matugcmcmall new materials for inspection.❑Ya NumatuW a tequlmmctu mhr Qupu ti93of tK=9oyCoh25505.25573.rd25531.1un4tnaMthr ft buildingora totcuvm that It 4 my toapomibilitY m ratify tie aevyant of Ncmya'uctmma marr�y�aanroancwr o<ttp�:r. Signature of Applicant Date
er/ a .for tot arH.d aiD u All roof coverings to be Class"B"or better