00100210 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT CONTRACTOR INFORMATION:
IIUILDING AUDR29 PCRMIT NO
10554 N. BLANEY AVE_ AIR DESIG14 INC 1h01.00:''110
OW NEIYS NAME: APPLICttnON SUR DATE
JON CROCKETT 85.3 COTTING CT 10/1/2000
IONIC SANITARY NO. CONFROLNO.
(707) 452-0123
0.4 AI2CIII'rF.CT/F.NNN143R', BUILDING IlFIdMI'r INFO
O O OI DO ELECr PLUME MECII
�'4
z o LlceNSP;D corrneneTOR'S Drcl.nun'rI°N Job Description
OC Iheld,'aldnn Ihnl I real,kens',ander Provisions Ed Chap(w 9(ronnpemmng
HHo m F W will,Secllnn 70y)of Div on 3 orthe Hmmc.s.md nefcsunn5 Code,and ney lieu,.
n 11,11 tome and efl"Lls, _
Li"caleCnls., de# INSTALLATION OF GAS FURNACE, 100K FTUS.
1
Date conlrnCler
ARC(II'ITCT'S DECLARATION
FJOQ d n InY 11 '.IIIb rel Iabli,occond,
W}
Ia�ip0A.......II 'I - w
7777 II OWNIIt BU1LDIR DECLARATION i•�/.4,/...'�`//r
Ihereby.fl d plI O C t. ( 1 I' he
rI-
�Zd Ida g .(Si 91D19 II ro CI Any 'y oa
hil11,
l,
q y F I IIIa p d L I I y.mcwm
prig rel I u,6 I 'tl WPI' II I1e',ll II g Wsalclen
m - FE,hr.,Ii...Fard par,con II the Fr nn,or [I,c Carnal I LEE,(Chaffer,1) Sq. Ft. FloorArca Valuation
(Ln Ing w'nh Seddon 701Div' 1,,3"10,15n.1„erS and PmfexSinn.r Code)
I iLeni nucir nWt Ibcrednm and(on bunds bar 1,,c alleged cscmplion,Any yieled.an r
o,f SI....7031,5 by any appliaun(for a"I'lon SahleaLr lac upplictml ton civil Fannlry
of act ante[Ilan dyenandmd Annals(S500). APN Number Occupancy Type
❑Lar cfthe 1reperty.or Fly e,np,oyet with wages as decal compersulion. /.q L71171
will do FEE,enik,pad the I I -.1, I acribled or offererl r (Sea 70,14
DLI are,,FactI r sadan,Code The Coe, 1'"'Later[-a,forI "ply,o I Required Inspections
f Fac,crtyWh n W ( 1,v.. II IwaaJ 'h Lh',roeir
mmngh(lir III employeesmm
.Fnlvided dirt sari ntmrovae ,am ILL imm�dcl oI 301 — ROUGH PLUMBING
00,ard Ca sale IT howeaa"the needing 1,r imprmemml(,s nnld widdn elle Yen'of
a,opledon.me ownlILife,win have he 1, d,aof"cavi.,.Ann he did nal I..r
per er ,or all 303 — ROUGH h1ECHANTCAI.
ne pnr"nv
.304 — ROUGH ELECTRICAL
L)I,u,nwnerorthe p(Seerl7Del C raiaival yid Penlingwine Il File
Conlruclnn In
n,LEE,Fee,
Lt.,sol.7daa,Rll.rnms pad Prly Mar Cl in,e ves halt en, 505 — FINAL FI_F_CTR I CAI_
License Law does 1,a Drily to ci nwner of pI'opa...y won nal'' nnnrnvca thio he
ane win nonlmnr. ror.Ilrn Pfniprl,will a conlmton.)deren l "nrsllanl to he 507 — FINAL PI_UM13I hIG
Con,ratnP.Liccmc L Sec._,
c
❑Iran escnepl,,anal spa. ,dvrerar n,is lvason 508 — FINAL hIECa-IAIVI'CAt..
Ownu DILL,
WORKI?R'S COMPENSATION OECLARAI ION
I hamhy u10nn ender penally of per ane,r the follnw'mg dedsadonn:
d I nova and will Inuinmin a C,liOcmc of Conwn, ,I y,If-ill rurc ror Workcr'S
Conlpomalion, o. provided for by Section 3700 of dr, Lahnr Codc, for the
"aformFro"Ed the work Ito which FEE,gamut i.....Led,
❑I have and wall Inainwin WELL 1,11',Core,neit caumma as I aired by Sretion
370L of the Labor Cecil,lin r If,,perl(,ruwnce of III work ror which(his panel,it
roved.My Worker's Camponr,eion Immi ince varier and I'nllcy numner am'.
Coll ('alley No
CFR I'IICATION OF E.%EMPI'ION FROM WORK(?RS'
COM PP.NSA'I'ION INSURANCE
('lair xdlnn need not be nnm"ImW if,he permit is Crone ImndaM dollars
IS 100) ,,ler")
I really d nl in the perh,rmmce o1 me work fel which(III,palmi,I.Lsuul,I
Lad not cal,loy any person ill any n r s9 to lactone,subject m the Wol
Comlpa,.alivn Law'S or Clia,Datnlln d.
NOTF am
N'c oine TO object
to
AN Wor':IL adiaCon perking tad.Ccniticrlc of l'at ptCod you.heal)
laeennrc whjeia v,aha Wnrk Forl'i pen a[Ion pm .one 1,l l d Lahnrcode,y1,, nus,
O Q rennwbb rnlnply'oh.nnb"m (.Inn.�rinL.......li.a,un be eeell,m a.vakw.I
CONS'I'RUC'IION 1ANDING AGENCY
I hcrchy a0irat man thea is a cn,alnl tion Irnd ng rg,ncy ror tae"'PECE
A h,wort:be wnidl IN.per m,I....nm(s,e:3097.Cr,c)
Lennie.',Nmne
z Lander'.Addles
V O I Tey II IIIlarve Feet]an ppl'', Iran FEEL'(hI tFELL]...Ik
FTr Fy
....... E' I ply II .(y p d I t l - r tang
O U
...brillia, ( real,1 II ly II 1 vu f moity t, r,
�y rye Iia alone.IL, 'T ed Fly IDI n,ec 1 p nes.
Q1, (We)agmewrllve,mdmmuly and keep hunnle,,me City of CaperineagatoW
,`moi Vd liulfdi(ics,judgn,elds,cooll and exlma.u'bill may is any way acme againsl.aid
City IF]cen.ctlucnm of Ate gmnung of mil Fnni(.
SAPPLICANT OURCE REGULATIONS.
AND WILL COMPLY WITH AL(,NON-POINT
TIONSIssued by: Date
Slgnnuvc or Applicant/Gmnmtor De,c Re-roofs
IIAZARIOOUS MNIILI11ALS DISCLOSURE
wuiIF,np'nnanlorRELIEF,intFair,cvllpam slom or hcill,I,doo mIL,dal Type ofRoof
E,defined by AIL,Call'. MIIIIIIIIn1 Code.Chepmr1)12,and lot I III amt Snfaly
Codc,Sce(ian 25.532(ad?
El Y` FI No
All roofs shall be inspected prior to any rooting material being installed.
Will the illiberal"I'fatic,Inihlmgeeca all caadFmt,t,Irdevi,o."bell If a roof is installed without first obtaining an inspection, 1 agree to remove
nithateact mr ennlnminanta is defined by the Rey An:I Air Quality Munagnpeal
,(rill' El all new materials for inspection. Applicant understands and will comply with
°`r "° all non-point source regulations.
I I I read the ha,ardcu,mmcri:dr reauiremm�a ulldcr Cbopler 6,95 of me
Caldiernlo Ieuhh&SdayCodc,Sxlimrv25505.25533 and 255311 nndcnamd than
if the banding dam nor currently hacc a ma'am,(hat It 11 my 1"F r"FIF'uy to notify IIIc
mupu , it which mall be me(prier w izamnce of a,Cenlfcnle of
Oreap..",
Signature of Applicant Date
Owner,or analan led a,ln( D,,,r All roof coverings to be Class "I3" or better
OFFICE