00040066crrY Ur curaxrrNU rt
nun,mNC oivtsloN PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRFS !�� yf �(/ �
/albs l�r r (rW k �. -T• O E I % SANITARY NO APPLICAT ON SUBM AL DA E
OWNCR'S NAME: ize ; '39th Me 6"!lw \.. / ~QJ
J NIC CUN'1'ROLp
HDNC yo 2Sa 036 �G .�Ny, l�//I /,� 9sct�g �
ARCHIT DENGINEHR 1 CZ�O C. '�✓�S a BULGING PERMIT INFO
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oi V I hemby afTirin Na I ca iiumed uMm provision of C 9 (commereing Job Description '
F_e wiNSmtion]000)of Div'sion3ofdrc Business avian Cade,aMmylicvueis �q,�y1s [{(—'� y�( 1(/
in hall force B q Lin» O
Rim' s� 4 �oli tf � � '� -TPA/
O i u Lic Clan „�' VV``�� .
u.O� ,D C ConuoWr ^ r,`f•/1g( /]� /1 /�— lJ,
AR RECTS DECLARATI 1fsrV /L� 64jad k � {J { .JI, r e ZS
my plans shall be used as public a cords '
z
iL
nS seem reaa . • 6w., e�`� " OWNER- BUB.DER DECLARATION � JOS , /�• /ys� /
e"
I hereby affirm It I am exempt from the Contractors Liccnee Law for the
i F O fulw•in8 rea: . (Section M3 1.5, Busirest aM Profusion Code: Any city a county
iC which minors a permit W construct, stmt, improve, demolish. m rtpair any nmetum "
a m Sq. FL Floor.'Area u lion
' "t he its issuance.
ven dpmuaregahe pmvisionsofrw n per oe W icenw e w (Ca p(er 9 - v
Ihet h<ie licenstl punuem to Ne provisions oflM Canaaaare License Law (Chager9 _ Q
tcameisexe pttheMro mandoneburnsforarNeBUdexa,mon. nyvrCnde3or ApN ear Occupancy Type
Sec he is exempt therefrom and the arms far me subjects the exemption. Any violation of (� • yr!*•y
that nor m man by any aced &11t for a famous Ne applicator a civil penally of
not more Nan Bve thuMmd dollw (55110).
6uthe work. end ro u Dens mi I e mows csu NeISole cons names
❑ P Pe x Y Poy a g Pe ..h. Required Inspections
q P
will tlo lesion, aMNe he Cmeieotimeodeduron, Met a So.]BW re - /� •- '
[al ( ,Bail u
and Professions Code: 'Ibe ConOamw's License law does trot ePPIY no 0 owner of /✓J, (�
his o ny who build, or vidrovu Neuron, pr who dre[ such work intended or w Ihmuph
his own employees, provided! Nat each .. I, old w w not intend w olfertd for ' • - '
m axis. If, hmveveu Om builthe bur ien ofpmlen ithat he did n t build rof compleniom do s -
wncr- buildwwill have Nc burden of proving Net he did not build or improve for per - - P. a o salv ow o•
71 1, u of the property w exclusively onal converting with licensed contractors m ,
construct the project (SO. ]fan Business of aM Profession Code) pr Contractors and
canoe law duo ret applyje an owner of property hms who builds or improve Centro, aM
who eLvdsfor[wM1 proluu wiNaconhxWr ([)Iicenv4 PUrsuenlW the COntrumr6 r ' •� �9 v- �,
Licenm Lew. ,
❑Iwezmnp under Se. tB &PCfor Nis reawn'
Owner - '- Data - -
WORKERS p COMPENSATION Of th. fRATION s'
1 hereby illhrm under penalty se Perjury one of Ne following d mere m:' )
❑ on, have
.'nd will erl font i Section of Co Labor Cod,. a part rma ce Of the
sation, m pmvidW for by Section 3]00 of fire Labor Code, for she perfomunce of she
k for whicM1 Nis permit is issuM. .. - 1
I� 1 have end will mnlwin Workers Compenaetion Inurutc<. m rtquimd by senior - t '
of theU Code,! perfo eof the work for white }oM.
� MY Wor meti cartiu and Palicy� - Zn /Q - `
Carver: Policy No.. f/ar - -
. CERTIFlC_ ATE OF P- %BMP170N FROM WORKERS' - '
COMPENSATION INSURANCE - (This I. reed rot be completed ifdw permit is future huMrald i.IS 100) r
'. or lea.) u .. •'
employ anytNtin Ne anyna oser of Ne work for whichtto the Niorm*Conpen- v
• not employ any person in any manor so at to became subject to the Worker' Compan-
Applicant
nt of California Dam
Applicant
NOTICE TU APPLICANT:es Co malting Ni¢visios of the Eumpdm, you should
hecome subject y she Warkda Compensation pmvisions of the Labor Code. you mum - - • forthwith comply with mete provisions or this permit "I be deemed revalued.
CONSTRUCTION LENDING AGENCY 3
I thereby affirm ham then iaacamtiuction lending agency for that perfomunce of ,
z the work for which is permit is Issued (Sec. 3097, Civ. C.) ' s t
[� } Leader[Addmaa s .
L]d ' I cenify Nm I have man this application and sore Out the above infomution is "
Pr Gi comet I agree to comply with all city and county ordinances and since laws reining to -
;U O buildingconstmcdon, aMhaethyauNOdu rcpraenwivesofthiscityloemfupon Ne
- mentioned property for inspection yumaaes.
(z Ew (We) agree Ip save, indemnify e p harmless dm City of Cupertino against
CJ liahib a,judg nl <mh.M ex a ah may in any wayaccrueegainsl said City '
} fr7 in co arm mnti Nis pew t. n - • - -
f'F_ In A(11,11 NT YI NUS ANDW A.COMPLY WITH ALI. NUN- INT -
t.i Z St URCI. E(1 IA "rl NS.'
_Signs of Applican Comnnm Dote `
f RDOUSMATERIALS DISCLOSURE '
Will Me applicator or lhmre building occupant snort or handle hauNW [material Re-roofs '
as defined by he Cupertino Municipal Cadc. Cba,mr 9.12, eM the Health ad Safety
Code. Sution 25533(.)? pe of Rbof
- ❑Yes _
Will the Applicant or future buildingoccapon use equipment u1 devices which l roofs shall a inspected •. r to any roofing material being
emit haaudous am comwimn6 as defined by the Bay Area Air Quality Management in ailed If a r of is cost ed rthout first obtalning'an inspection
k/ I ee,t rem ve all ma rials for inspection. Applicant
❑Yu J_{No
r u rst ds d w' compl with -all non point our c regulations.
have Ne hsiarduu ala rcquiremen apmr 695 of Ne Cili- N $I
forma ulth R cry C 25505, 25 sad 25 . I uMCrsuM Nat if Um - / .i I . Q I1
Idi calm yhev mnoL rsmy rcs rbiliry Wn eweupot - ` C•/
o u hich nbe wto iauun<e cam of l]sc pumy.
re Signature of A cant . Ya -
lhvmro nhoneed a8cnt - pans -
Al l roof coverings to be Class "13 or better
OFFICE
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
•� • CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: karenb
Sec: TwP: Rng: Sub: Elk: Lat:32620024.00
INVOICE DATE......: 04/11/2000
REFERENCE ID U ...: 00040066
SITE ADDRESS .....: 10165 ADRIANA AV
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: PICCHETTI HECTOR C AND ZORRA T
ADDRESS ..........:
CITY /STATE /ZIP ...: CUPERTINO CA, CA 95014 -1125
CONTRACTOR .......: LIC H
COMPANY ..........:
ADDRESS ..........:
CITY /STATE /ZIP ....
TELEPHONE ........:
FEE DESCRIPTION CHK
__________
TOTAL FEE
PAID -TO -DATE BALANCE DUE
_ _ _ __ ___
BPERMFEE P
---------
117.00
------------
-----------
0.00 117.00
BSEISMICRE P
0.60
0.00 0.60
BUSLIC P
90.00
0.00
'_________
__ _______
_____ _
_ _ _ _ __ _
207.60
O.00K 207.60
V•ID DESCRIPTION
VOICE
ID DESCRIPTION
.. ............................
305 FRAME
........
307
-�---_- ...-
INSULATION
- 601 ROOF TEAR OFF
602
/
ROOF`PLYW00D NAI'G
603 ROOF BATTENS
604
ROOF IN- PROGRESS
3
.0
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• • BUILDING PERMIT INVOICE OPERATOR: karenb
Sec: Twp: Rng: Sub: Elk: Lot:32620024.00
INVOICE DATE......: 04/11/2000
REFERENCE ID # ...: 00040066
SITE ADDRESS .....: 10165 ADRIANA AV
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: PICCHETTI HECTOR C AND ZORRA T
'ADDRESS ..........:
CITY /STATE /ZIP ...: CUPERTINO CA, CA 95014 -1125
CONTRACTOR .......:
COMPANY ..........:
ADDRESS ..........:
CITY /STATE /ZIP .... ,
TELEPHONE ........:
FEE DESCRIPTION CHR TOTAL FEE
--------- - - - - -- - -- --- - - - - --
BPERMFEE P 117.00
BSEISMICRE P 0.60
117.60
Via ID --.__ E DESCRIPTION
o F ..................
RAME
601 ROOF TEAR OFF
6D3 ROOF BATTENS
LIC #
PAID -TO -DATE BALANCE DUE
------ - - - - -- ----- - - - - --
0.00 117.00
0.00 0.60
0.00 117.60
VOICE ID E DESCRIPTION
..... ............................
307 INSULATION
602 ROOF PLYWOOD NAIL
604 ROOF IN- PROGRESS