05110091 CITY OF CUPERTINO
BUILDING DIVISION PE T CON �TGiR II�T�O IOM'
.r. _. � _.� .a mo-•tiM. ..�.� ,w,.a? "
BUILDING ADDRESS: RAMCHANDRA NADKARNI PERM ND.05110091
807 BETLIN AV
PQiMTt LS112 DATE
OWNER'S NAME: ,
RAMCHANDRA NADKARNI 11 /17/2005
SANITARY NO. CONTROL NO.
NE
BUILDINO PERMfrrNFO
ARCHITECIPENGBIEER: ELM ELECT PLUMB NFLTI
i Kp LICENSED COMNCIORS DECLARATION Jay W,nation
£� wdsdmiuui o bwinr a� mPoa .�em�Ik n� Do '0Y 9
+ � htrour.adeBee
KITCHEN REMODEL
;g=q L.Cl a 'b '
Die APR - - 2006
'CW ARCHMIMDECLARATION
77 I uMcmaul my Pburdi alu+II x d u pubAc rcmrdt
Liu and Pmfe nil
y� OWNER-BUILDER fi DECLARATION BUILDI
I hcrtby.lima Nu 11- :Boat from the C odnod ra :my d Law for du
a o mlkwin,�rsanm SIn Is.Badaa add Pmrestiom code:Any dtr or:Dint $31000
3 9 whkh mryltn,pmmit m canmucl.ilv,hvpore,dcmuTu4 or-pa'm my mtnv-
t� Prlormhi ipuvcx,,pu-quimsthe applkantfwmch pamitio fik ad:rcd suuraru Sq.Ft. Floor Area Valuation
< diad Ito b Ikamd unow m du pmviri.a du Ca.r ,Is W(CluiPun9
(cor.matxin,v Ih Sadm1(100)-(Diviikn 3rf NC B usi.es muni Profaiou Calc)or
era,be b_MIX ,,Mfrm,ando tumid id for dm Jiq d ..mpd.Any• iadtioe of P Y +]�I
(�
Scalmt 7)31.5 by am pewit
Viiikma for a mhjau d-"Plkant u a CM1 Peril!d r Occu anC
nm mac ibm fisc hued-d dolbn(ML
❑I,u away of dk PmPc-Y,or or,emWyw whin ws,e u devsdc c-npenadm.
wiB dr tino w.*,add ikmnaame b not m-d.d m.n�Im ak(Sa.TBu,Budtea, Required Inspections
and Pmrecdmu Cade Tk Cnndaciar,Li—taw docs oat"ply to an owner of .
praWry who Wilda w imp is d Mucin,and wino dan,urd Wirt bu d"if or domt:b hid
a'wo=Pto d,,.pro d that suchimpm+emeb ate out ift voffardfoalo-If.
Ywews,on,Wiwi.:or iognru mrnt is mW within me Year ofmmpkdm,ikowna-
buodo,-ill hers du Wrda of pmvin:that k did.Wild ornnp for P'utP-m
,>r.).
1.u naor of tM PmRaf•w=hut cf comsat.,whin B¢ud®uactan b .
uwbam de Pmjm(See 7)M,Budnea and Pmfotdenf Code)The cunni ra Li
rmwlaw it.oat apply b,^owner of prop: y wk tuIW.or impo—deem,and
w W<msazu fm such pmFcu wla a canwar(.)Ik,nu d Para cant b d-Conuaa.A
Lim m Law.
Q l un...w,pt rd�S� B k P C for that rutin
0` Via ���a Data,
WO/RKERS C 5ATTON DECORATION
1krebya1M//d ,prnalrydPeaJoryme ofthe folbwigdcslndmti
I4.e and wm(nilnuioaCatineuo(Co��c�m mlf-iedme roawo ,CwnP
adm,u pmridee fm by Scsd.r 3T of de Labor Code for du pertaruart¢u dm
wink fm whkh dui,paint,is iaamd.
Q I b,vc and w U milmaid W.WS Cornpmsr{m bwvata-,u nv W d by Smion .
37)0 of Ne Labor Code.for ik peafaror n dtN -rat fa which dda Pamir b lamed.
M,wbu aCmtpeaaboa lmuuae omka and Porky-.1k,arc
Urrier. Poky No_
CERTIFICATE OF EXEMP ION PROM WORKERS .
COMPENSATION WSURANCE
rrhbadwudz vakc-opkid if do Pamb bforonchund,aid n(51BB)
orlac)
1 atif,Not u We perfwy�ma of tk wart for whkh Nb pvmit b,..,.n.l Wall om
employ any=n toayg itivwar !I to ei jeerm tk Wortoi'Campmadm
Lawi of UlJomy.Dice
Appnom
NOTICE TO APPLICAVY:If.afer rhadaing iia,Urifuye of EsetPdun.Ym.mum
k e,,ubj=to ik ypa '.C-np—do.Pm.idoru u ik Labor Code,you mus
.J 0forthwith rnmply witb aah pro i.a Nu Pamll shall k dmncd m r&
N
Z^ CONSTRUCTIONLFNDINGAGENCY
1 rorcby-Rum thw tk-b, 30Iudln,afor ik Pm{mmana of
du detk nor whkh Chia permit IS inud(Ste.3097,Cr'.G))
W 0 Lender's Nam.
� Z Lader-Add.
U I.atify that 1 hats red do,application ab..,that the abae ioromuiim b
LL
1 grt to cvmPly MN ill cit,and coumY ordinai�ad aM awc bin-Muir:to
LLt7 Wddin I%)agmtian.arta,inch idwriae-premnuthsd of Nb cif laenerupon dc
ahavemcndw-d pmpcnyfminilcNm ILIP—.
(Wc)agate w a+e,i.dcmnify and hap harmka ik City H UCupmitm a,aimt VI liabilideejudpneou.eons and ape"vwhiN ma,NUY nya.crx a,ilmt aid Clry
Uz ircoucquame of dm,rmbe,of ihb parva Date
^ APPLICANT UNDERSf[.NDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR UI.ATION .
C ' //•/7 O� Re-roofs
Sl,ralurt of App/liy UCarux+o
/ xAZARn0US MATERIALS DISCLOSURE Type of Roof
WIBy applicant or fmwo p.jCg ,Clba,tdartar hadkh tin dWrty
u .So by du 32(.)? Muxricipal Cade.rSapmr 9.13,aM We FiuIN and Safcry
c-k.s<wm nvx+)� All roofs shall be inspected prior to any roofing material being installed.
❑Yc F(No
Will tk.ppllentw fmu-Wlldia,a¢uPam umcpdpmatar @vim whkh If a roof is installed without first obtaining an inspection,I agree to remove
•emit baeardrn air co.wniwm u kfiortl by Ne Bay Arta Air Quality Mana:emert all new materials for inspection.
Dwkr Ll
❑Yn 1d^u
Ihate rcaJ the hoard-uowcdalt rtgtinvnuu uratx ClulAv 495 of de Ulifm- .
ria Fkal Jtk sdm Lode,sv r, u,k.o, nadtra.1 uvk-anddtn, nr ch:
drn„at r w.c.r,,.n.that It b y regamlMliry m mdfy de occvpar of de
�� .y�ar.cwywmaroanparmy. Signature of Applicant Dale
i l All roof coverings to be Class"B" or better
n'.....�.,„t..,.. ..eo, Dam'
CITY OF CUPERTINO
m 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # : ' 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 36927017 . 00
DATE ISSUED. . . . . . . : 11/17/2005
RECEIPT # . . . . . . . . . : 31980
REFERENCE ID # . . . : 05110091
SITE ADDRESS . . . . . : 807 BETLIN AV
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : RAMCHANDRA NADKARNI
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4546
RECEIVED FROM . . . . : SABRIJA KUCEVIC
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : RAMCHANDRA NADKARNI
ADDRESS . . . . . . . . . . :
'CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4546
TELEPHONE . . . . . . . . :
4WEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
----- - - - -- ------------- ---- ------ ---- - - ---- ------ - - -- ---------- ----------
BPERMFEE VALUATION 31, 000 . 00 375 . 84 0 . 00 375 . 84 0 . 00
BPFIXTURE UNITS 2 . 00 18 . 00 0 . 00 18 . 00 0 . 00
BPLANCHK PERMIT FEE 375 . 84 501 . 56 0 . 00 501 . 56 0 . 00
BENERGY PERMIT FEE 375 . 84 180 . 40 0 . 00 180 .40 0 . 00
BREMVENSYS NO UNITS 1 . 00 10 . 26 0 . 00 10 . 26 0 . 00
PPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
BSEISMICRE VALUATION 31, 000 . 00 3 . 10 0 . 00 3 . 10 0 . 00
ELECTRIC SQUARE FEET 110 . 00 8 . 80 0 . 00 8 . 80 0 . 00
EPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
MPERMITFEE FLAT RATE 1 . 00 38 . 37 0 . 00 38 . 37 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 1213 . 07 0 . 00 1213 . 07 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------- -----------
OTHER 1213 . 07 M/C
TOTAL RECEIPT 1213 . 07
•
I
es.;.
t� ' RE_S'IsD.E^NTaIA�L ROJiE� C-'OvEaRSHEET
• CUPEkTINO
Assessor's Parcel Number:
Name of owner. Ih�MC h Ri►D 'IJ^f_�(/�(G0412 /Ul
Project address. O, L 1 r J P7y C
Contact person. SOA , '1� C��1/1� Phone.
Fax.
Net square footage of lot.
Existin Proposed
Square footage: First floor:
Second floor: �-
Garage:
TOTAL:
Are there at least two 10 foot by 20 foot clear spaces inside the garage?
• Is privacy protection planting required for the project?
On what floor(s) is work being done?
Brief description ofwork. (.C—t`100IE�L V-iTC_KU-0 ( CPLKE, Ghll-DCS 'JJ 64ock)
A-Ny T P�Ti oyc-ogz
Code editions: 2001 CBC Y - N)2001 CFC (Y - N)2001 CMC 4Y,- N)
2001 CPC & N)2001 NEC N)
Effective 11/1/02
•
Plan Review Process Work Book Page-8-Revised 4/28/64
oOJ ,G
ER
N
I
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1 F-
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. �°°�Z� x,021 I,
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W�WER-BUILDER VERIFICA40N
1. (Check one) I or my immediate family (parent, spouse or child) will perform
A. All the work authorized by this permit
• B. = A portion of the work
C. None of the work
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A _ All of the work
B. A portion of the work (complete section below)
Contractor Address/City. Phone # State License # Type of work to
in pErfa=ed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer(see reverse side). A
• Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.'
Persor;/Firm Address/City Phone Number Type of work to be
erformed
........................................................................_...........................................................................................................
I declare under penalty of perjury that the above is true and correct I have read and understand the
Owner-Builder Information(reverse e).
C"o iVa✓- 17-- Zoo
Property Owner's Signature: /` Date:
M��
Job Address: Q �ATL Aj r, V Permit#
Any changes to the information Provided on this form shall be submitted to the City of Cupertino Build
Department
•
city of Cupertino Building Department
aITYOF 10300 Torre Avenue
C U P E f,T I N O Phone: (408)777-3226
Dear Property Owner.
An application for a building permit has been submitted in your name listing yourself as the Mulder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit Building permits are not required to be signed by property owners unless they are
personally performing their own work. If your work is being performed by someone other than yourself,you
may protect yourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and m have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work
(including materials and other costs) is$200 or more for the entire project,and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding, federal social
security taxes,workers compensation insurance,disability insurance costs,and unemployment compensation
contributions. •
There may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish,the US.Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed contractor or
subcontractor,only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit,erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors maybe obtained by contacting the Contractors' State license
Board in your coumturnity or at 1020 N Street,Sacramento,California 95814.
Please complete and return the enclosed owner-builder verjfication form so that we can confirm that
you are aware of these matters. The building pemdt'i i l hot be issued until the verification is returned.
Very truly yours,
Budding Department,
City of Cupertino
prb7w m Recycletl Pam
rC CITY OF CUPERTIN16
CUP
EYOF P?KNIT APPLICATION FORM
APN 4 -�5 ro 21 O I � Dat
ePdress V dv— Ill 200
Building Address: ) Mailing Ad (if different from building address):
50.1 S-ETL 'rQ �v.c-
Owner's A-MPhone
ChAN MAD A ZrJ I
Contractor: License #: I
Contact: Phone:Phone: (J&-527-1$IZ Cupertino Business License#:
SR R CES I c Fax: yvg_ 36y-1263
Building Permit Info:
Bldg &` Elect Plumb 9? Mech E'
Job Description: , p
Residential k-IT �
CW MOkbEt - Commercial ❑
S4.Ft. Floor Area: q.Ft.:
Cost of Proiect: Occupancv Gr uD:
Type of Construction: Please check this box if the project is a
v f
second-story addition: ❑
roiect Size: Standard ❑ Large ❑ Major ❑
Quant ity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appfiances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> l OOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1,75 M Btu MECHANICAL
BBOILER5 Boiler > 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTTO_BQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax -Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENTERGYADD Energy Add Multi BUILDING
BINVESTIGA
Investigation fee BUILDING
• � ��
1 of 3 3
012/ 3 . 07
ti CIM
TY OF CUPERT�
OF PT APPLICATION FOR
CUPERTINO
uanti Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING
BNIIT'IGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUC0l\CVA1 New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum . PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIIXTURE Pblg Fixture PLUABDING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interce for PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BLUDINTG
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUIYIBING
BPSEWER Sewers PLUAOING
BPSPRINK Lawn S rinUer/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPT'RAP Kitchen Trap PLUMBING
BPVENT Alt of Drain &Vent PLUMBING
BPWATER InstalUAlter Water Pie PLU1\M1 NTG
BPINIHEATER WaterHeater/Vent PLUl\0PgG
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reins ection Fee BUILDING
BRElvLACOVER A/C Unit> 10,000 chn MECHANICAL
BREMA.IRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY .. Remodel Busways. ELECTRICAL
BREMFIXT Ligbting Fixtures ELECTRICAL
BREhff URN Relocation of Fumace MECHANICAL
BRETA URNOV Relo Furnace > IOK btu MECHANICAL
BREMFMAT Heater Installation MECHANICAL
BREAMMOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREM'IPOWER Power De-Oce/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMaEPALT Repair/Alter Heating MECHANICAL
BREN=SAPP Remodel Res Appliance ELECTRICAL
2 of 3
CLUR AY OF CUPERTINO
CITY OF PERMIT APPLICATION FORM
CUPE{,TINO
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Sips Add Branch ELECTRICAL •
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lightirig Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISNHCOM Seismic Commercial BUILDING
BSEISNUCRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSVTIM Swimming Pool BUILDING
BTEA11P Temporary Power ELECTRICAL
BTEMPPERNI Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERNIITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MTERNIITFEE AZech Permit Issuance NfECHANTICAL
PPERAMFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
PLLONGRNGC Planning LR Comme/Multi-Fam PLANNING
PLLONGRNGR Planning Long Range Residential PLANNING
ZADDCHG Address Chane BUILDING
3of3
CITY OF-CUPERTINO 1n, .rcy .�a"mpa.x�r.� 7147` �1"`-' ' x
BUILDING DIVISION PENT ti�A+�l) lu'>C'`fTQRIi A�. AT—P zx,
BUILDING ADDRESS: RAMCHANDRA NADKARNI PEB"Mrt"°'05110091
807 BETLIN AV
OWNERS NAME PERWr ISSUE DATE
RAMCHANDRA NADKARNI 11/17/2005
E SANITARY NO. CONTROL NO.
ARCHITER/ENGINEER BUILDING PERMR INFO
BLDG ELECT PLUMB IIECH
(� 0
iG8LICENSED CONTRACIDRS DECLARAflON Job Descriptio!
iUn C w' I Ecrtby JBrm Nu I an,,1a uiWcr P+w+'�°s of CWPW 9(comms g
U NSmbtat7010)a(Dwi,km3aNe 6®mv and Profu,km Code.,nd my nano 1,
+ mrw ramaneam KITCHEN REMODEL
±g Z Ilcutn Glu, Lt.a
F Q
Nit, Cawncnr
W7 ARCHRECfs DECLW AnON
1 Wdoruand my phns,lull be bN u publk
: �
e Cleated Pmfessioul ® a
y�3 OWNER-=rn tfr DEdin cnn ION /vC O6
7 I hcRby alTirm Nu 1 am aempl fmm tro Cmuanar,L,,nan Law for Nc
2 G O r0flomr,i rumn.(Satiart 7031.5.B---and Pmf�«n Code:My e0y«rounty
5 3�+ w,,,,,Rgn,cs•Prndt in cmowc4.1w.imPoK.d mown.a Rpair any sxm A $31000
_iy privrnvinuanc<.sl,o Rqu'...IbC sppliCLtl r«,w P«+^Il io rJc.nlmd a;unml Ft. Floor Area ,.Va1'vation
< ( hebIkcnscitpumantbthedDismaacatsCB-IiiIX',IJalmlr(CM )9 Sq.
(nit,k , oS p, Salon 7000)aDlvtdun]a Ne BvdttarsuP Pr My n Coda)«
e�- �im�gy anyw Ott ro.�h Rhe+w mtm�i�oar
r Occupancy Type
W mare Than five htttdmd daft.(5300).
L]4 u one atro papery.ar my empbycu with wale,u Ihet,ak cmpmntfoo,
itdo
and Pafldn..CcaaddeNeTveunCWmeudaaro«hitvLelMmeude aLaw of tintapply n7014.Bui1 of Required Inspections
pvpcny who bu0d,aivpvwa dvrm.and wiodou,acnworkhlmRGar Wovlh hb
Ory ernpkym,provided Nu enb ivlmRmmta aR v«Ivtm f t'«affeted tarsale B.
Owner.
t,:,buildingto IX vopovcmmtg tat rilnlitarcyur of mm In,IEearrcr-
buildn win ha,e the burden a pmWti that he dW tnt band ar impure far pvpve a
vk.).
/ Lai nwncr a the pr.,ny.m uelutively.4"ni with 1i¢t mnuanm in
�tauaty die poj:n(sec.t01a.Budnea and Pra(evka,Code:)Tic Conrand,LF
m•-lar doe eat apply n an ow,tar a pttpmy+ho hWlda«impo,ss thetem,and
wro rnnuacu fa smh Om}ena whl a cmOnar(i)Bcettad parwot b dr Caa,aear,
LkLa..
I w nrmScc B d P C f«this taaam
OwonyLC �'� Dec
WO HERS COMM ENSATION DECLARATION
I bnebY auap under pemLLy ar perjury orc a the fauowin{40
cI IW.e aM wW ttWe•CauftoteaCotamtb v0-m,ne(a Wonlxf,Ctatpem
cation,v pwidcd farby Sembo 3'1(10 a Uc lab«Cade.rIX ttr performancea the
rch Tar wl"Ihiap ft is i,nad.
❑1 n,e and will maimaiv W«tel,Canprmatiuo Iynu,race,u rtgtdred by Salon .
3700 of the 4bar Code(«do pcdarmana atna wart r«wlkn the permit u Wird.
My Worlds Caatperadm innvanm a and Polley numbs M:
C,ln: Polley No:
CERTIFICATE OF E FnoN FROM WORKERS'
COMPENSATION INSURANCE
(TLh tetdm rsd rot bcmmpknd If ft perch k rar one hued do0a,($100)
ar lea) .
I anihwt m Ne Perf ova a th wart far.Eich tN,perMt V Wmd.1 dun mt
empbY anyp=nin Wmi='r'my:_atinn
law,a
Appllont NOW:TO PPL1G :If,afla nlainj Nu CWfian EiUnn11VM Cu,hm
yaW
bccanc,vb)<cl b Iro)IXkd,Carnpcneticy po.tcau a ft fah«Cady,ym mm
.7O faMwith mmpry with,vel Pra+'Ida^+ar Ni,permlt,Wfl Ee deeme4 ncrotcC.
Z CONMUCIION LENDING AGENCY
[r Ilntmy drum the Vert i,seawrvtim fudini,µsy(«the perfvmana of
D: > the wort far rnkn Nis pmnit b usueE(Sec 3097.Civ.C.)
fol Laydds A .^
= z ludeh AAM.
1 aNfy Nat 1 N,v Rad the appltvim and,uk Nu the aEow Wmmtlun V
IL0
Ltynat I b=Ply with W City aN CMUI ardi .and stale Ian rtWivib
bu0din5 cttWnnnim,anti bsRbynW«ISRpamuian, he it ofcCity m in upmth
C , -nbtummd poKny for Impmum purpnet
(We)spab C.loci ex yand IRP hanm� Goy aCupvtmaal 01144
City
UZ intonabaiiql of m,.c«ue.d ecpen,ee ni;n m.y m.ny nyaa„n aWntv,au City .
Uz APPl_Iquratc,WMERtlac antin5aNl,pvmit Date
^ APPLICANT ERSfANDs AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR Ul.ST10N1 r..
C a /— 7- OJ Re-roofs
Siitulwc of App( HALSRDOUS MATERIALS DISCLOSURE o.x Type of Roof
Wa Jamar I.bu11Nn5 occupan sac«nanNc lata mstvW
at dabcd by dte Cupntka Municipal Code.Cbapta 9.12 cad Ne Health avd Sarny
ado.Swim 255334)7 All roofs shall be inspected prior to any roofing material being installed.
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win tro appliam or mme hudini 0=p"Use quipmmt"dk wNch If a roof is installed without first obtaining an inspection,I agree to remove
.dt bv�air contaminants u iknmd by do Bay Ata Air Qafily Managcmcnl all new materials for inspection.
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I bite teed Ne hantdm,m+talab Rq,tctmvta nbcr Chapter 695 of Ne Can(-- .
viaHWNd Wn Smim+25505.25533wZ553/.Itoo-savd NairN bW[&4
don rot c mrc a lrnavl.Na,it i,my cv* biNky n mufy the oeeupwr or de
ttydtmtc whkbmuRbeatnpnx .C.0 anaaaapaaay. Signature of Applicant Date
All roof coverings to be Class"B"or better
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