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Permit Signed off in system'? No other pennits open or expired in system'? Location of Approved Office Set? CofO Application.doc revised OS/17/l6 CITY OF CCrpERTINO BtiILDI?��G PER?�TIT � ---------- _--- � ---� `RI?It,AI\G.ADDRF.SS: GO�iR4C"I'QR: 'PF.2�IIT NO:B-2616-123k � !10592 CtiI.,BERTSON DR CliPERTNO,C A 95fii-4-?55((37�34 034) `H(?tv1EG4V\L'R`13UILD : ' L:K � ------...._..------- — - !U11'VER'S NA�IE: t31SNAj:�rtdITA�4ITRUST[F C[T:\L iDATE ISSL;ED:(l4'0"--'016 �__ _._................-- 'O1YtiF:R'S PHO\F.:COR-1,63-?323 ', I'1101f.10: _ _.._... _._. _ _--- ---- _..._. _ . ... ...._._...__._— LTCti\SF;D C(.)\T R4CT'OR S DECI.ARATIO�ti 6CILDI\G Pk R��1IT IVFQ' License Class L;c.# �Contrz�mr HpMEC�VJNER/BUILDER Date ',�[�LDG _ELECT _I'LU1IR ': �iF.CII Y RESIDENTIAL C0;�1�IFRCT�L !I hereU�'uffirm that 1 am licensed under the prurisions of Chs�pter 9(com�nencing '— — �x�ith 5iction 7060)of Dil�isi��n 3 of the f3usiness K Professipns Code and[t3at m� '� Eicense is in full force and efl'ecC. 'JOB DESCKIP"fIC}N: IC:O\STRUC'I(?�}ATTACHED 2t�D L:'�1T��'ITH��2 S.F. 31 hereby afFirm ander penalty of per�urc one of die Cot[ow�itAg I��o dcdarations: i. I h:+vc and wiit maintaiv a ccrnncatc of consent to sclf-iiuurc for\�,'orkcr's C'o�rpensatinn,as pro�-ided for h1'Scetion 3?00 of the I,ahor Code,f:��d�e performsnce of�[he���urk for�vhich[hi�permit iS issued. � z. I h��c and��ill mflin�nin\1'orker's Compen,ation lusurance,ac provided Cor hy ; $¢ctioa 3it0 ce`dfe Lat�or C'�de,For thc perform�inc�of tnc wnrk far ivhich ehis` prrmit is issuact. i Sy.Ft Fluor Area:?ti4 �l'aluafion:53600C�.(}p -w.—T �.Cl'_i,l.�:]1�i�:I3.T1E1S:.�T1Q?Y ; , I certify thai 1 have read this applicaUon and state that the above -- �'���"���� 'information is correct.I agree to comply with alI city and county ordinances ��'��umber: Orcupane� Crpe: ;snd state Eaws relating to building construction;and hereby aufhorize ?'S�4 039 De(erred Se�hmittat(K-;1,A-3(Cusio,nl , _ ______.__�_ ____ _____1 ;representatives of this city to enter upon;he abave mentioned property for inspection purposes. (�Ne)agrea to save indemrify and keep harmiess the jCity of Cupertino against liabili;ies,judgments,costs,and expenses which , PEIZ�IIT EXPI_R�S Il+'L'1'ORK IS�OT STARTED � :may accrue ac�ainst said Ciiy in consaquence o`the granting of this permit. '� �,j�,�� �g���.�'���,P��'��,�,jsSU'�1��C�OR ' iAdditionaliy,the applicant unders:ands and mriil compiy with ali non-point , 1 � 'source regulations p2r tFe Cupertino Municipai Code,Section 9.18. ]$O DA1'S FRO'1i LAST CALLED I:�SPECTIOti. ', 'Signature Date 417/2�J16 I Issucd bv:Ahb<<Avcnd� � �i D�te:0410?F2G7 fi ()SV�ER-B['I[.DI;R D�E' ',I.c1RATl0\ � 1 hereb��aftirm that 1 am exempt irom tbe Contractor's License Luw Cc�r��oe o(the B-�=l3�nfS: i'olioning h�o reusnns: .Atl roof�shaA be inspecied prior m��iy roofin�material being io��slled.(f a rcwf is I,as e:wner of ihe property,or my empluyczs�i•i�h 4uuges xs their sole ii�stalled«iilioirt fiist ol�taiiiing ait 4:�pection.t a¢sez ro rea��o��e all new m:iteriak;f��r i�`��, wmpes�ation,wifl do Uie work,:uid q�e smicture is tiot inteiided ur o#:ered f'or inspc�tion. I sale(_Scc.7044,Busivess S Protecsi�ns Cude) I ;y�z I,a>owner of tL`e prcrperti�,ani�•enntractine��'ith]ic:�nsed Signutute�f lpplicanl: � ���7 conu;�ctar,u�consuzrot the proiect(Sec_7044,Susiness&I'rufessions Co�le). Dste:4.�'%'_Ot ti i(hercG}�affirm under pcnalh uf per}ur�une of tlie fulie�wis�g tliri•e deil�rsuions: t��,L ROVE CQVERINC5 7'C)I3E CLASS"A"OR L3GTFF.R 1 ._ I havr an<!e�il�mimt ein n Ce.hfic�ite oC<.c�nserrt to vili-insive frn\knrkt:'� i I Compcnsan�n�as proa�dcd fo Ly seer.un 3�OL o:chc Labor C�d4,to�.Vac � prrfoiniance of tilc work fer i�•hieh this pernrit is issurd, i HAZARDOl1S NIATERIALS DISCLOSURE I � t ha��c and wil?maintain 1l'orker's Compensaua3 Insurance,as provideri for Uy � [liavc read the hazat�duus materials requirements undcr Chxptcr G.95 of.Ihe � � ��� Section?700 of die Labor Code,fo:tlse pe�form�nce of t(�e ieork(or which this I Californis Hesltli&Safen�Cnde,Secfi��ns 25505,25533,anU 2553�_ I�si11 � ma[ntain contpiiance�sith the Cupertino Afunicipai Code,Chapier 9.12 end the I �� perntit is issued. �a. 1 cerEify tliat in thc gerC��nnancz of the work Cor which this oemiit is issued,1 fleaith&Saleh�Code,Section 2553?(a)should I sttire or handlc harnrdous materisl.:�dditionalh�,should I use equipment m�devices ishich emit hazurdous shall not empiuy aoy pe.on in any n+annzr so as to becom:subje.t to the i;�[r contxminrnts as drfincd 6)'ttie Aae Area 1ir Qualih�?�Tanagement llistrict I R'nrkzr's Cnrnpcnsation 12�cs nf CsliFornia. 1C aRer making tliis certiiicate of ���iII maintain cninpliauce+sitli rhe Cupertino�'tunicipal C�de,Chupter 9.1:and ; exemptiou,I become sahject to the 1+,'c,rker's Ccnnpen,s:ion provisiuns of t1�e � the Ilenith&Safety Code,Sections 2i�05,2gc33,and 25g34. � Labor Code,I must fonhwith com}�Iq v,ith such p:o�i�ion�or this pennit slaali c -- � �,n. . be deemed:eti•okcd. F � Owner or authorized agent: Yti '- '�'' k^�'"e-'S ~ � .4PPLTC-�!�T CERTIFTCATtO� .Date:� � �I certify that I have read th�s application and state that the above information Is COiS'CR�C,'I10�LL�I31�[ �t'Ji�CY � �correct.I agree to compiy with all city and county ordinances and state la�vs �hereby a�rm that;here is a constru�tion lending agency tor the performance� irelating to building constn;ction,and hereby au;norize represent2:ives of this ciry of work's for which this permit is issued{Sec.3097,Civ C.) Ito enter upon the above mentioned property for inspection purposes. (tiNe)agree !Lender's Name ito save indemnify znd keep harmless the Ci.y of Cupertino against Iiabilities, !judgn�ents,costs,and expenses wh:ch may accrue against said Cfly in Lender's Address consequenca of the granting of this permiL Ndditionally,the applicant unders#ands; 2nd��iii compiy with all non-poini source regulations per the Cuperdno Municipai �E2CHITt:C"!"S OECI.:�R;1`ft0� Code,Section 9.18. i i understand my pians shaii be used as public�ecords. � � , ; j�,�,.,��`,�",' ��.'-,� ��r`�`3 Licensed ; `Signature!J" Date�J�Q�¢ Professional � r-�-----> ;---�'------ ---- Cfil-OFCI'YkR11.\OH�IIA[\GYt7L\1IT'l�tii'F�CiIONCARD ---�--- — � F-- — — �Ii[ll.11i\G ADDRFSS !10:92 Cl.4BFRTSO�DR GY)\TIL�CfOR FFx�tiT�n �t1fPI-]?TINQCA 9i0143556 li-2DICrl�tfi ON"i}R'5\:1�iP: --- — —PE3L\tfTLSSI.�FIY. 1b5�_KI C1��3EX"fSU\I)R CUI'F72'IINQ.CA 9ip13 Bf S��'AS A M IL�1=A TRUSTF.F&ET A l. (N'U7r?016 - —�--------- -- ON'\tR'ti PfiO\t'_ � PI10\ENO: . --�-- �JOB pESCRIPTN)ti:� --- — _+)?<ti7"RU�-1�":�.4"ITACf�FD2\D UNff IVITH 3S'_'S.F. ` 7lPE 1�51'ECtUIi IIAIE: _ � ' Pzt���� ---.. �,���� �(}�,k y (���� .�-�� -� � ��� ia�r=2rncx,�nc.�cP�Pivc � • �" � INf)ZGRUItiT�\�':1TFF � I IIVI)i-l2liR()L%�nSF�4'FR i.�� .,�'� �,,�>rx�t�»;k '��: -���� ; ��� �-?'C?�� :`j�(� �I RCKX;11 Pi.l'\Iltlti(� ! � ( — I � CHO\i"ER P�K � I -l�:.TfR fiF4l':lt �5R".4�EIi.tiF..✓,17t'f � I: ! —__—�_�" ._____._^.. I I � i ��(.'S Pkt tiSUFCI.I fl� � T . . ._.__'�.� —'_'_'�._—_ _ 1�.�,�41 F�R�t��'L�f 'PRCNWEftTYU\F.CiEARtN_.'IT—� + �:PI.L'M11iii.\4;FI\At. �_._"__'__...�—:'— eLserwc.u: ! I �:r tK i �' T O ARIL��c�LNS PkY-n0� i �'� Cal)777-322R t�ct�sren 7:30 vm and 3:3D pm\LmhtV through Fritt���,n�Icx4t'_a hnun tkfore rr�}�ired � l,'r�)F.KGRo.NU L �; inspec6oa Ji�bnckkess und Yerntit\utc�crs are needed��hen recp�estin�an ins�wction. !�•w�x��k ; ':j -- — ct�r���:�:os��a.ax���srR�cr ( ��ict.�nir�.t:ciK�c'.v. � Clmedcircuiriieioinspectiunufprtipet'h�lixcleauou[.puintufconnecti�n ��Prr:,n�;•nx.�icv^oH�t.krut� ; andsfreetlatcralrequfredFxior[oryssingf7X4LC71'1'PLU11ftIiG �— LVSPF]CI70ti Call the Disvict(4118-?53-71171)fur un appuintnKn� i . �)('It\'ll'L�1( lU- ' � �-,k�� r;:E „, � r � � r ��—! `c�ntmnnc��rs��seerno�s��-ni.nis.ueRtnafn ' r-., , �---.._ _. ---- - i`'}{_. ---:,-u �=� --- t3U51VNJ5[.[fE\SFS ARF.073T:V1:D ; ��l.fCl'Kii i'iti-1t. avi-:i�rt��ic,:ai. PFR'�4T�1PiRFSIFti�'ORkLS\07'S7-:1R14D\l�i"I'HIti180llA1�SUFpt72�)f!' � ISSt'AVCEOR IRO b.41'S F720Af L1STC.A1_t.tD ItiSPFLTlO\. � �'Utiltff�x-R -- ^_T-- -- � �c3;x�H 4i�t.tL��:aC:tl. LIIPORT:1\?�1�hen a�xrnut h:tt eaprecl a charge totatin�nnc�icd d�e fees tn ahtaiu�ney�rrrnut j �---,------ �: a,. —��— � nmst Ir�niJ in orcler�o reacti�atc thc prnnit.tf a Errn4t hati bcen eapred for mnre i LRVAM'iC than rnic�•car,a charge�aoiliM„ihe fee�to olK:iin a nc+.µ•rnri�must tx}aid �---_�------- ---- -- � i . 41R CP�{�:��u�i�2 to reactivrte the pernut. � �ftX1iJS_ __�—___.,_ � ; � F-------- I �\4CIL41i(tl 9�nL � � \U7}�: � �- -- ----- � � �✓ /'1'`���'� �//�"j,L-J n/�� '1�L_ �.u.��� � � �}���,,,� ': �- - L,,��--.� ��/�� � ::,f,�,�:u. j �� ,r—..__.' __ � 111 1 i�\�7f":ii. I �----- � �HCi;�)!�G �—_'__._ ����,:f: ,, ,,� 7 .7 �_-_ -. ti1\91Ullti(:IYXIL ' ` 'RI':t\!'l�:<�"i��tiii�:'7 _ i r----- � .�:�,,, �---- r�ecta�o�t uo�r�c � fKK)FTG � _�_ --- T----�------- i 'rr[;•:s•t>c�!c M •_ i�-------- b r ir,�t o�4 , � " — ---..--------'..- — --- I �vt.�vr _�_ ' cu�ir;v, � i ��-_—_�_---------- — - —�--- — -- —� �;� r , � �` �, . [�?� �' ,�- �� �� ,. ;��' t� '.�•_ ± � . , � �' ' -------_=-_=--_-- - � � TSTF. [\tiPF.CifNt D.�7E—{' T\'PE ___.,J 1.1.ti1'F.C7f)R� �UA7'E � ��T1TE 1�tiMF.('T[Nt UA9�f. �_tT�4�D.tllO� � PLI���ifti�(: ; ': ti-1:�17A1t5-IiNiYECiI(Nti____ �� �K7ri�cti i� � `,.j� �>.,� n:n1�i�:P.��: ��� � �;��tx�tckcn�'� y �t9:� ��.�-�^�t , � .NA:IiN III:4TC3L � I �IIILNLOF'L191 _ �- �PIF7:S � Ll4'ATt�R54Y.4iC'c ' �.. l�dl4nt:Ht_A�15 '�.C4STI�JT ..`_ T'11i1.(Ct\"nWC.S . ,�. i � � ' !tlCii-if tff lV�Y � r�:\rt.v.iF�If.9 ! i(lS�It:l-kR NFLILSE � , � — _ � GRCri[11�'SIIF.\YOR6 �!; I. 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