05110054 CITY OF CUPERTINO n> :�'w -..°•�` .e4 ` "
BUILDING DIVISION PERMIT 4C0 RAG-T INF,OaR&MATIOhi` �
BmIDINC ADDRM: LINDA LAINE PERMIT ND.05110054
9
"tEh1I
NAME: PERT L4119 DATE
TDA L•ATNE 05
NE SANITARY NO. CONTROL NO.
ARCHI'IEC rENGINEER: BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
ZZ
.0 LICENSED CONTRACTOR'S DECLARATION
w I hcrrbY sRrm Thu 1 w tianxd otwm porlsl«u of Cmpm
cr 9(c«nmcin5 Job Description
i with Saon 7")of Division 3 of the Busircu and Prolrushw CodW e.0my lkensu
arwuabeaWeIIa ADD 1013 ' (LIV. /FAM. /KITCEH) &
Da CConhactm REMODEL BEDRM/BATH/LAUNDRY/DIN.
ARCHITECTS DECLARATION
I mdcrww my Farb NJl he used u puNic rteorN
lirnsed Psa(cuional
OWNER-BUILDER DECLARATION
hro soot Net 1 I- cumpl tram IPr Canau7Co Liccuc city
o for the
HC whichfollowing rrs a (Saban]IDIS,B ether. srrr Pt, ort li it.m Any airy ar ectomy
$ which rtyuues.droit to mYbINCI,aIle!,'vnprme,demWlsh,m minor my swcturt
AZT
g�o$ P^mtkIs litSULwptrommmt to
to Provisions.(
fmm C..',l Ucc...Lsw(Ch,CpmVcN9
Sq.Ft. Floor Area Valb6852
(eooncromntswith sewatt]0DO)ofitro3ar
lbs evdlta,.na Pmrmmncme)«
3—
but h is eumpt thertfmm"Ne Now I.We sperm......paam My vionis or M
Section 7031.5 by my apPlicnt for a pmmit ubjtm the sppBom b a civil pmshy of APN Number Occupancy Type
va m«e dun n e hundrtd dollars(5.500}
36924042 . 00
❑I.vowtla of Ue poParr,«ay wplq«s wiN wwkeaulhev sole mmpenWon,
mmoms.ons;C Thj,�,art,.hsC,I ea«1w(rooS L Psly 10In.Of Required Inspections
pm Psofwho nor Cane:m thotrorm,Littwho lbw urt ml hinsi f u oatth is q P
ptonm who hulls«impmut himpr wnwho doeasuwlumthims Jr«Wmu{h his
owesempby hipin,a idlutechim 1,smenksuenalipkmf cmpkrim
h..ft boo ilre ou m ofemau 1,sow withinarc Sur of comfor,Neoo,or
bulWa wi0 Ease ae buNm of Forint aur he dol nm Nilld«impms Im puspos of ■ �®
uk.).
❑1,v owrcr of the patimy..m exwtimmly cmins tr wM I{mued cootnown;b F'NAL
carwrvm the MJT(Sec.7061.Buutr W Ptofculou Cade:)M Caauscmrs U.
mos Law does n«apply m m owtlm ar properry.wba builds or Impose tic...od
.homna,nal«.uclip*Nwtli.cora,m«(b)I-n,edpar>vaNmarGamr..,orn JUN 36 2005
❑lam umop lm See .BSPCfmblstcuan
Dm
�COMPENSATTONDECLARATIONI ��� ���
1 bereby affirm uMer penalty of perjury one of llsc following dcclannms: a
❑ o,m std will for bin aCenl 3WO of ft LNb v,lo,fortf«o«fmrn cmnpen
.uivn• r pwidw for by Savm 3'1(10 of Nc Mbar Calc,for ttr paformaoce of the
w"""
wk for which Nu pcnnil u iv«.M.
❑I naK enol will,0ainbin workers Compenuaan InuRsna,u rry,drtd by Somian
3700 of the Lab«Codo,for ab pmfotmance of the work for which this Fermi,is Weser,
My Walsers Campeasaam Inau.na retia enol Policy mmnkr art:
cm .. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Tris xc,im nrnd noth:mnpletw If ate pasib u f«oor honed wlLrs($10(1)
or leas.)
I mrify W I in au Nrr«maue of the wvrk for which Thu prmil is issued.I shill not
cmploysnypctsonin NY Wub subj«Ib NC Wartms'Comp"•.m
Iris of Ca foMa.pale t/�' "
NOTICE
OTIC u E aftcr—
NOIme s7O .Coropcmoo 0H Ccsioms of
Euanplo d you should
become subjal y w Wahuu Compeuathis omits"of the ubQ Cade.you mlm
wJ rZ IonhviW comply with such pmvkti«n m Nu pro,,shall be dratuH rcvotcC '-
zO CONSTRUCTION LENDING AGENCY
[+�N+ I homby sBirm that Vert is.canvuctlun lrndln5 a5eocy for Ilse perfomonaW
C4 tM wok for which W."pumit u iuurd(Sc 3097.CH.C.)
aQIrndrYs Nsmc
=z boder.Addra
U O 1 mnifr wu I hue r this apiliaion and sate lhu thn ahos informu4m is
cm nc.1 sirroo to comply with W city and county ort irmor,;mri sure bib rtW n5 to
OU buirinS consuunioo.sM lsmeby molunrite mpuentxi of Nu city to mta upm Ne
G shove.menamed pmPcrty for imps .purpasb
(We)spm in vee,iwcmnify and kap hamliess lis Cily of Cupmina swat
,Fy rn labilhLon,judgments.costs and cap.which may In my way..6siousnid LRr
U Z in....cquenaofth SnWh,.fthis permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 12- 2-4-6r-
SOURCE R UiT10~lS. I Z I �/
� Re-roofs ^�
SI lion
HAZARDOUS MATERIALS DISCLOSURE Due Type of Roof
win lh apglionl«Tulare bwldinp occl+P+nt care«bsndk haudoua marerid
ss hErud by ate CupNno Municipal Code.C W pN 9.it sna ft Fi b mil Willy
E3
Yeses tsvzan *No roofs shall be inspected prior to any roofing material being installed.
Will ate applicua ar foram building occoloon.wuip,.«a icca which If a roof is installed without first obtaining an inspection,I agree to remove
mh hnor iif cvnbminsnu v @Oma by the Bay Art.Ah Qvulry Msn.Soment all new materials for inspection.
Disuict7
❑Yes Al No
I havertW the hva loo,normals mryimmcros miner Chapter 6.95 of the Calior.
M,H1 lhk Safety Cad.Sad«u M5 .u533ad25534,1umlctnudW irar Wild'ms r
d«a rot l'V,enity he.c s rind«,aw It u mY rapotuiNlitY b mafY tM oaup.nt of ar
tayaimmeNa a,i'—"-c=rkmof;�7/,T- Signature of Applicant Date
All roof coverings to be Class"B" or better
conicr d sVn1 Date