06030139CITY OF CUPERTINO
FORMA 40N.
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�+T
BUILDING DIVISION PERMIT
I
kcor l.laCT WIF
BUILDING ADDRESS:
SB I
PERMrr NO. 06030139
22036 ACACIA WAY
^ "VER'S NAME:
PERAO- ISUE DATE
HOMESTEAD RD LP
395 DEL MONTE CT- U1�3
OS/19/2006
PHONE
ty f
SANITARY NO COROL NO.
(831)274 -2518
ARCHOECT/ENGINEER:
BUILDING PERMIT INTO
BLDG ELECT PLUMB MECH
LICENSED CON tACrOR'S DECLARATION
Job Description
1 herby affirm than 1 w ucem,d tuador Pro^ of Cbapier 9 (commencN{
vitb$a4LYt 7oDu)arDiridaa 3 ofdte ButimssW doonam Sp m. and my B¢tasu
inmu(OrF and effax 0
REVISION- STRUCTURAL.THROUGHOUT
`"a' Conlrslm'
D ate
ORIG PERMIT #05090179 -NO NEW PERMIT
ARCHr1ECT5 DECLARATION
1 undo W my Para shall W nod u public rocmn is
lia�ucd Prof,sdoal
OatNEm DECLARATION
ca,oDER
1 hmhy .Rte oral 1 from Law for the
Cismon fs
Co de: Any can armumy
ar R c: My
I.. Buap Pr
doiam
wllbhmqui.a. Orotii to cm13,Bnsiness
wh6L ICQIdIm a pGmir m rAaWUC4 al4Y. hnpoac, dCmailsh. p RPiir any 9fYLtYrt
! prior W it, iaswrta. alga nAUimthesppltcm for suchpernitmOkasignedmmemem
' - Law(Cba m 9
Sq. Ft. Floor Area
Valuation Y
$0
that lc0, lic,. dpuvunton NCpmnOauoflbccmacooe'Ir
(cmtmonciq with Section 70D0) of DrriaWn 3 'tic Buaima and Profcmon CO&) or
that W h camp rand ao and the bash for Lb. 1140(1 —a mdu My ADILdan of
APN Number
Occupancy T[ pe
Se,9aa 7031.5 by any applicant for a perm[ mb3,aa inn appllam m a civil prnalry or
nmmaroda°EwW ^md�0i'�0D
32602067.00
❑ Lnowner of the ptopary, ar my wpbyem w0h wap udtelr aok mmpeuvdm.
Required Inspections
q
m on de wadc cadW traclam is not lam d or oBcrtd for sale (S .7044, Bad"°'
and Pmfcsdnns Code The Caavaemfa Iic law dm -1 apply n an — of
pmpeny`'ho WBds Or improru denim. arol whodou aueh wort him dfor(kwib hil
w
owu empmym.poryWihu pch hopmc sa are oa ik croffeW far sale. if.
(I
tmvety. the bodWu,l or Ycpowncn a sold within arc Yar a-- Pkdoa. ds owe-
\ /
builder w base thn W Nen a priming that k did nit b iW or knpros for papas a
\Q
❑Lru,weaathe .mancOsaoy eonos+inl with I) s ema.mpan
construct (Sec. Bnlnea rod Wm Cade) The Ca Li
oe Panjot
\/v�
\\
oy wh themo ,
ams I�r don rm apply m an owns a property rW brim or heprowa Wemz. and.
r , La apply "an
who concerts for sacY ptojrcu Nth a contractor(a) umtscd purannt m the Conu.aofa
L pns Jw.
❑la ,..nip order See ,B&PCfa Nis revon
m
Dale
WORKERS COMPENSATION DECLARATION
I hrtby am- ceder peoaly a Pajmy one of the loll ntrduuLx�
Ibow andlI 'Can of Canso m - -fe YPOh,faCmpco-
-
sloe•
ponded fp by Secla 7]00 of the L Lor Code, for the pafarmuta a We
suka, for 3-M
am, Ia whiN Ills pewit 41mrd.
r
❑ 1 lase and ml maioain Wortels Campenuopt Inpuutp, n O,Wmd by
3700 a the Labor Cade, for the peRp of e rort fa which Ais pmh a lmi
My Workefa Cma3p,uati � amkr aM Policy nm w:
Gnkr. `JfIaTr. 1/ Polley Nu.: ^ O
00
. - - -mmFj ATEOPEKEMPn011mo, 'O
COMPENSATION INSURANCE
r
(IL's scion , oath, cmpksd ifibe pump Is forme hmdred do0ua (Slog)
p Ira)
1 pray Non in Nc p(f.c a Nc wort for whit Nis pnmb u iapd 1 sIW I nit
emPby any person in any .r so as to bete, ubjcd to Ih W ftri Compemulm
Laws aCalifamla Due
Appl op
NOTICE TO APPLICANT. If. after rr kj this Ceninan of Eaemption, you ;;;kJ
bpmte subjon m th,WO 3 Compaaadon pmNsfaa of th, Labrr Cow Too mace
fpNwitb comply w'rh mcb praNakm or this Patait "I W diluted masked.
UCnCN LENDING AGENCY
Cat
hcmby thanth eV•aJ lending for du Perfam.n¢a
thOm
tLt wont for which leis pemtll a t..,..n (Sp. J09T, CW. C.)
which s". 3 .)
.
L<MeYa Awe
'
� L<MeYS Adthcu
I certify that I haw pad Nis .ppiicLUon and aan than the above W romadon Is
^ tartar 1 aya to comply with all city and aunty Ordinances and sale law's tcluiot m
jWiliins ctinanution, aM 1crtby..t1mn :mpresaatiw of Nis city n ale upon the
a mcmioncd Pmprst far lca c PpNSma
CW) U. to nw. iadrmtdfy " Ittp Itumkat the Cly a C'ertnto natmt
bl apeuea which may in any way uem,.Ldna rid sty
nincoua, lad {meows
ramms
Z icesmcgseTUNOERantinsaS AND WILL ^ APPLICANT U ST DS AND WB1 COMPLY WITH ALL NON-POINT
SOURCE REG O
Issued by: Dale
- 4, 4MAN;
/— - --
Re -roofs
Type of Roof
Si". or ApphanUCmaantt I / -.Dw
HAZAFMOUS MATERIALS DISCLOSURE
WW on appticam or futu, bock mg pNPutt norc orbmNc hmNOUS ma trial
u daiond by the Capmon Municipal Cod,, ChgW 9.12. aced the Halth aml Sacy
s„dan 25572(')7
[D Y. �(NO
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
w,u th, ,ppia,t p ramro Wiltline mvpam ax cquipmau as which
emit haisdan air lofiad by th Bay Arta Air @why Maoapen,p
all new materials for inspection.
DAri t
❑Ya
1 have mad th, hanrtaa oasdals rtquitvmns Wcr Chapur 495 ante Califp-
da Health 6 Safay Cork Spdma 25505.25533 and 25534.1 unthunand thulfttr b ikilnj
dru nut evrradl) , temnl thu II v my a,rypdality n mify the aaymn a the
raq °'9'awb metlrlorokp,taaaCuaBCOcar
Signature of Applicant Date
t- 6/19 06
All roof coverings to be Class "B" or better
Owner or auNari> ,sal / Dam "