06020153 CITY OF CUPERTINO �1�,� 's/�° e'i �y-�' '' ' = '1��r�
BUILDING DIVISION PERMIT CONTRACTOR�L�r TION u_
BUILDING ADDRESS: PERMIT N0.
10564 N BLANEY AV
ER'S NAME: PERMn ISUE DATE
JON CROCKETT 13675 LONG RIDGE RD 03/21/2006
PHONE: SANffARY NO. CONTROLNO.
(408) 781-1400
ARCFBIECf/ENGINFER: BURRING PERMIT INFO
BLDGELECT 0 PLUMB MECH
30o LTCENSEDCONIRACIOR'SDECLARATION JobDescribon
I hdmby Aran Nu 1 am Baso undo u pnmxioof CluPur 9(=n=erving }�
IN Seoion"IOW)ofDivinu n 3 of the Bost.ao Pmfn Code.AM my li¢ u
°
m full Wrrz REVISION--ENGINEERED WALL ROOF SUPPORT,
Lkute - /" - MOVE FURNACE, WATER HEATER, LOWERED 2ND FL.
t� Dau ARCH ETSDECCnLRATON NO NEW PERMIT ISSUED/ORIG. #05030153
i o' wtlnwo my plus Wll o ucd As In bb"
O .B✓i=065
v o t; Limned Pmfe tonal
3 OWNER-BUILDER DECLARATION
1 hdroby affirm that I Am cumin from No Cont Ws Locate Law for Je
a O falhr vin,renvn.(Section 703 IA Bud.And Pmfesmm Codd:Any city our county
i$ which rtqu'..a A p nrrit to cnrsuucL Aur,improve,drmnlls or moral,any u Ium
prior to iu'...uncc.alsumquiru iLcapplirnt for such .it to fika egad WN .l
££SC Ron M 4 Lkcu minauot to Rx provisions of di Conau ¢Nonose law(Chain 9 Sq,Ft. Floor Area Valuation $0
Y $ (mm hang Midi sealon 7000)a Divluon 3 of the Bwinn+AM Pmfusiou Code)a
.. Nat he Ie in Jcrtfrom AM Je bus for the Akjo.—Ptlat.Any rldadan ar
S«tlon 7031.5 by any appuum fora Permit abjeda du applicant to a civil pointy of APN Number Occupancy Type
oat mme Jun B.e bundred aaNn(ssoo>. .
'11 6'jnj ng In
❑I.nowrcraNe pepvry,aury cmployw Midi wajuuttrurok mmpcueJm,
MJI o die wort,ao the abucwrt a Imt Inuvded IX afvN for oak(Sat ttNa,B W oro
And!PmfnAoru Coe:The Cantnno/s Licetsse Taw don not apply n in owh or Required Inspections \\\\
props Mynb.MsmlA Ron di imin aoi dosA sb Mort oroaeu,dNmandh.
lbo,M ,9u,buiding oddutwaxsnis Bond cart and
lmvtdcrmplcoed for aver-
( (�
bods,, Rlbar ldinj bumban f mmnla sold didnhers,of cwmpktioor Ju owner- v
builds MB bane sh bsndm of povivj Nu K did rot holld a'vnprove for ptapue a
sok.). ./
❑I.u aOh or the ,,c. ,B uG andl conaactinj will Ilanxdoadu
constrvcl Ne Proms(Sec. r An s W of aad Py nah l Code)The Coovc .Lt
ase Law don not wpb n in with of.Cto Y Mn,bWLds m horram W Ra cursor.AM
who oonLxu for oath Pmlew MIN•covvacnr(a)Rmt¢d Pursuant w Nc CanuraaYa
Lireox law.
❑1 em evmpn Moa Sec. .B h P C fm IWa reasov
Dae
Or WORKERS COMPENSATION DECLARATION
I bertby affirm iodcr penalty of Perjury orc a n followinj dc3asatlans
This:it for
byS.U.
Ce T70)a Comecon udcifor fa 'f.Caoreo-
workr povido far by Saban 3'/W a cite labour Code,for Ne peuanmarce a We -
wtak for MM1ieh this,permit is issued.
❑1 dive And wort malmaln Wats/s Carnpmmkm Iwuvss,u agtrho by Scm.
3TW of Nc labor Code,fa Nc pafor a of Use Moil for wblN this Antonin is Isysed
My Wo a Cwml�euAqlon yInm�rqares tuner ao Policy numberarc:
CERTIFICATE OFIXTIONFROM WOR
COPSATION IN KERS
MENNSURANCE
nrbiz cctlm ren tm1 be comPked If Ne permit Is frcme hondro di0an til WI
o tau)
I a+ufy Net in Nc pufmmm a of Nc w fa which no,pumh- ' 1 t
trophy am pcnon in any on u a ' m 'Cato
La"of California DAc'
Applicant
NOTICE TO APPLICANT:If,Aur matin]diL&mme a Faem W
become nublca no die wok 's Cmvpenadon Provisions a Ne Labor Code,you mtw
Ofo
rNwiW comply Midi h oucgavitiau o Nu permit"I be droned rmmtcd.
z N CONSTRUCTION LENDING AGENCY
I m.by aLBm NA Naci,a'a Iiimt lemine ays for dw tarfm s
y'> Re Murk for which this pumit At isi(Sa.309'1.Civ.C.) .
W Q lantke's Name
z unckri Addmu
UQ 1anify Jut I hurt road Non apnii,Wou aM sus NA de chose inromutwnis
LyH corm 1 ajrn to comply MNall city and county oniiurttts AM start An .rolaningn
�U Wildingcon tion.andhcubyaudiorrcrcprocnutimaof Niscltytocntrulnvt Nc
W above-meotimm Pmpeny rw inspection purpmca
(We)agmc to saw,iocmnlfy ao Iscp humins the Gly a Cupdrtino"aiun
Lind lRka,judlMons,cons And npeun w may In any May..agaMA said City
(J7 lncPolr�ucCq.of y�trourbits a Ws _Q G
•^• SIJIJtC V ANDS AN 1 COMPLY WITH AIT.NON-POINT Issued by: Date Y
IV/� ?�Z../O-&: Re-roofs
Sipbl_=of ApplkanUCmtusaor Dane
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or Imus building oaupw a.or baMk Window material
As de0rcd by We Cupertino Muninryl Code.Cbapner 9.11 and Jr Ha1N And Safuy
.Section 2x532(.)7 All roofs shall he inspected prior to any roofing material being installed.
[3 Y. C
Will tic applium or room building oaupam uc c Pnpmwt or ticviaa which If a roof is installed without first obtaining an inspection,I agree to remove
emit hear in romarnin"o dcOno by Nc Bay Amo Ab Qtuliny Mvujcmcm all new materials for inspection.
Du=ty �] .
[I Y.
1 ban road the WArdms mikRals rtqubaseiru undcr Qapidr6.95 of Ne Califo-
maHnINkSAa Codc,Sa-tlmn 255(15.25533Ad255M.1 I
din ifde Wilco
6
Jan wt arrondY responiNli - Je oxvpant of Nc
roquirtmcros Mnc m '"a a. .[a d Signature of Applicant Date
Owmcr or awm N.Fcnn rote - All roof coverings to be Class "B"or better