00020188 CITY OF CUPERTINO A ' PFaMrrNo.
_ BUILDING utvtssoN PERMIT CONTRACTOR INFORMATION: O 0 O 20 / g g
BUILDING ADDRESS;
,`` pyo Q� SANrrARY NO. APPLICATION SUBMNTAL DATE
�I N'IC CONTROL;,
PHONT' V`J (/ i lY V tf/w y ❑
ARCHITECT/FNGINECR .Y\�_. (JS • r�x/` BUILDING PMNIR INFO
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LICENSED COKIR.ICIOR'S DECI.tMT10N
>- �' I Icabr affim Na I am liemvd roam p.9vi.imr nra,pet 9(e9mnemint Job Description
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C O ARCITI`D TSDECI.SRATION C
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u1 R OWNER.BUBDFA DECLARATION
C z 1 b•*ehy aT,h•t I am nemp,ham,Pn C9ntrac c e:An c law fa,le i
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rdwwint�.Iseedm M31.5,apupmma9r� cam
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.aa. :Any iry«manly oO to
a wniaa,eyw,.parol,m eauvae,tl�c,improve,mnolw,a,eplt my,mcmte SLI' Ft. Floor Area Valuation
pvaio imm«,.Ian te9ulrt„he applicau ra,vch pami„a elle.dOd weved
,hu be i,lent ip,u,uu„o,be rovmm,«IN,conuaaot,Limi,c Law
(CNgm9 e- /�A�
(1.4wiN SeNoo M10)«DiH,bn 3 oftbe Buum
o . P,«e,
and iompm
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,hu k LL nein,, (,our aW ftb..i,for ft zBet,d eaeopi Any valid.« Nu b Occupancy Type
Sacdon 90313 by my.pytioa fa.pemut mcam bjmta,be applito a civil peulty« 2
eo,maa,lun f ve hwdtcd ddLLr,13300).
❑ I.urn.�mNewwmr,«mremwa'm.w;mw.wnme;*,ale«ntpmmino Required Inspections
w W m,le wv,k.,od rin,anrtva u no,imendr4 aoRaed fa Wc(Sm.9014,Bmiven
am Pmtm,lan,Com:T Coovanae',License Law dour M apply,o At mniu«
p,ep wWholed,« lintel
tad who donu,chwart hint.ath,ao.
N,awn em .the y,p,. .di n w rowno 4en,vR.an,on intendant a pRemd to
We.If,how'ecn the b9 tJne «i„q,m ,LL.oi,wlNin one yea«comdctior the
nwmrLuilde an tiK dant unam«po.;pt Nan Ie dal�,law a inQmw r«pa-
porc«ula.).
❑1,as t ttie of Je property,e.Wi4,H cacluuvely copuaj;n.wiN Orad emioiw. -
mimLa Ne purled apply
o an -ixoHotof
atal R«m{b i Com:)The Con,tc,al,V- I
omrc law docs an.pply,o m aroma of p,opny who Wildn a ium,vw.,hcmd.nd
whom,Law,f«a,N paojmv wiN.cmv.c,a(r)licetr,ed paruan,b ale Co«,aclaYa
I:cauc law.
1 mi aemp pMn Sec. .B k P C f«dtla rcum
Owrc Date
WORIIFR'S COMPENSATION DECLARATION
I Avcby affirm uMan proal,,«Perjury one«,k folm intro Iauios:
❑Ihavc and oriel m.invin.CaiBcue«carom,roaeB.N,mc r«ww«'.c pe„- LBy utim,u pno i f«by S«don)900 of Ne tab«Code.f«the peAf m N,snunito I have and w R nW,fort o perf Gamem.te Tom wh m m9 ,W Dry 2000
3900 of Ne tabor Cade,to de pafomutwe«thc wwkfw hick tw permn LLlmrdM Mbfkel,CyQpmyun lv 'ryty i=TE Policy t OMWORCERFBICATE OF SATIO TION FlIOM WORKERS'
COMPENSATION INSURANCE.ammnamPprom, ammeal )
a lw.)
I«n;ry Nat to Ne perta,nanee or Ne wn,t ran wla<h NLLPe,wt LL luued.l fou
ea,aopby avy pvmnNmr mmnmmurobrca,ewbim,othcwatrrlCgoWm-
,nim law,«raaani.0.x
Applicud
NOTICE.N APPLICANT:If..her evki tion ro enonk aof Pae«pti«S yw,IwM
hecpmc mb3m,y , Wa4lo Compenrul W ernilt w,«ale lata Com.ym tnuu
fmNwiN canplY wiN ouch povl.lm.a NI.paml„he0 W dcenN rnokod.
z (7ONMUCnON I ENDP O AOENCY
O O Ihrtby alf,MNeei,.comuucdm Rodlot ate,Ny r«,h perfa,nuttnf
7 e .N
wort(a which Ni.Prm,d,u iard Ism.J099,civ.C.
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CG 7 lameeo,W,Addreca
fr7 A I C fy,e,e to
l Wve,rod all
ia cit yallu,ion odutwo es Ne above i,Jomwiov u
= z mnm,.l ante to aWl wiN all ci,Y ab cno^D vdwnca and.ixy on . upon
to
tine W.Idmt comwcu�vtl hertby aalmss tpose"oW iva«Bd,CRY b vw upm Nc
4.1 0 above-(W.).l propnty for inanec,iao i keep h.
O [.. (We)q,mmuvc,"expfyand troyhayinanyk Clly of Cupertino apmu
V li.bilir;et Judtmm,b.ca.ua,dc.pmnwkcl,may in mY wwY,«me ataim uid City G .�
_ 4' 'AITU4CANT UUN EBJSANDS NII WILL COMR.Y WITH ALI.NON-IO1NTIZI
V z ST3URCE REGULATIONS
Slt,raouc«Applipnt/Conuac,m D„n -
H RDOUS MATERIALS DISCLOSURE
W01 Neepplirant orfo,nte WMint omupav,,,me a I.Ba,hamrdoi.material Re-roofs
u mfimE by Ne Cupertino Muwcip it Code Chip,,9.12,vd One HuIN anal Satiety
Cade.Section i3531(07 Type of Roof
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Will Neapplicant aronne W,Mine, ia,.ot.'t pnentor All roofs shall be inspected prior to any roofing material being
emi,h.vNau air mnnmiun,a to.deRpN by Ne Bay Aeu Air Quality Manate,rem installed. If a roof is installed without first obtaining an inspection
•
Dimiea❑Yn I agree to remove all new materials for inspection. Applicant
understands and will comply with all non point source regulations.
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I.lrnlN&surer comaSex-tionsSex-tions505
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itea,enta.w he me psi« cmira,e ar D,epp.,ey.
Signature of Applicant Date
fTvm«auNmlred.iea Due
All roof coverings to be Class"B"or better
OFFICE
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