00020154 CITY OF CUPERTINO PFRMrr No.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
004o� O
BUIWING ADDRESS: / - ,,
Z n I O� ✓�S� `m — �ph L l �/t C SANITARY NO. APPLICATIONS MnTAL DT'FE
OK'NGR'S NAM1f Ii��� / /✓Ip (f
N/C CO.Y1130L
C:
. PHONOO
ARCH
TfECr/ENGINE[R � / �' • ! ��/T BOILING PERMRINIU + y `;
�00
C
U d
7 LIC4ISF CONfRAC11ORS DeCLARATION
z - 1l�etyarmpN,LIamlieemedoo�poor arcn.pm9f=amnemug Job Description
wiNS voe]000)ofDivivon 3oflW Bud®.ad Rofessiam Code,aE wry lssueu
Fxi Nrw ferea.m arm.
tM6 LaaCT.v R g,723rF? 8 Rem":&( �Ci tcltPh GtKe( 3 �gE �iraoveu
IAse Catvma y
C LL O S ARCHr1ECI's ce oN
tlufl u.ml to publk 11 v.m
Ks�a
PMea mal
A'a OW NER.BIIBDER Dt 0,c ATION .
i=2 M 1 bvcby afire Nan 1 Im eemp form Ne eizi near. -My c Law no Nc
f D ro oSilumi.(Secllat ]O)IS,Biuim..od Au.� i tuck Amy can a marry
ansa. $ which mryiru.ymndo to mmwn.w1k i t for ro denld'Wit a rtpw.%.rmmue
phase 11--1'also
ntto cies uK.�be a fa.�ngtena'. 9g�etbapmee Sq. Ft. Floor Area ?0 Valuation
dantWuIlopr.d�tosixa Division
Sof Coeoacleas Lil L.a'(Chapmr Z (f 1J J j
(Codolt see.nom ttSsJ.on anti)dDliuo m3 dNe Bwixu udon, c 'vu Cadc)v
daL h.i,nIJ1 b Nm applicants
anal de wi.a Ing m Re e.gmpean.Any l peream d APN Number Occupancy Type
SCNm]O31�by any apPBoafaapamRmbjecu Ne applk.0 loacivil Peary of — 3 >— �6 St,h )
na ripe Oua fl.e Wtdcd dollar(5500). ^
❑I.uIdlWpapmlr.amrNw%m�m..R,..mor.gle�IgPm..am, Required Inspectiordt
w10 do lbew and the egl Iluglaled a offend fa sale ISec.]pLf,B.
and Plofusiam code:The Cowaria'.Lrsme lav don ea api 19 an ower d
piopmy vW W iMs or inlpra.a Ihvmn,and wW does.acb w hinnsH a Neopn
his own emPI y provided Nn R ioWrvrnlwu sae not inteMed a oRaed for
ale.If,how .Ilse wilding or wipoossoicn,L sold v thin one year al covgkoae.Ne
ovrcs-0 Wer vl hale IW Wide d pvvly ILt W diad mbuild sing efape-
❑I,a 1 ft c oi the See. ,,B gaclu aoci cwvacuy wuh:)meed c o-I&s U.[1 1,. NC plaj h(prix et t y,.BYY W..ad R atraanMi Cade:)The calPCml!u.
cmuetaw sine.m�apply m an ave d popery wW bolds a impove tbono ,and
wW coovaro fa rub poj.w .convaetor(s)IrwN pelmet In Ne cnna .
no aw y/
I mo u uMv Sen. B tO P C,flw'tlri.yrus-m V -
OwnerT.
linoWORKER'SCOM of'tnj TON aCLARAt10N
I hmebY afire oMer peaty d pmJllry goe d ds following dalvanioe: `�
❑I here W will mmnUm.Cauflurg dCoean m.eU.inwug fa Wohglacal�e-
utiol. r pori t Tor by Sg ia- JI00 d do tabor Code.fa Ne pvfavugcg of We
work ra wfiicn Ni.prep is erwi, -
❑1 lu.e.gd rill Ieivwn w«ter.Cwppe.aWn Imlmrc<.m lequ'ud by Secooe _
My dIhlabor Code,fa the Pulaournnd Nc wvlk nuwort Nup�eu Bhared.
MYWoiters Canlpeoutim Inruuec rartim.I Polk:numba.m
Cannv. Policy RO
CERfQ'IC OM OF NIMN ATIO UNN FROM WORICFJIS'
CVMPFI.'SAITON INSURANCE
(This.ectioa geed not W eoliplmcd if IW pmmt a faoee hind ddW($100) '
a kat
Ioy any pe in the p,non adinewk neobje is the w aiaad,I shill
oa gmpl%anY pron in any menner.a..l0 beNne"anRvt m Ne WaMn'Car� .
Alma ur.d Cwfmvi..Dec
Applicanar
NOTICE TO APPLICANT:If,atm nuking Nis Caoflu¢th exvnpim.yen rtaWd
bombe anr*ttoent y tl Watds Caepcnr this povi.:wu d IW Lebo code,you oma
raNwiN comply wiN.vch provHim.a Ni.primp.bB W deemed mvokd.
CONMUCITON LBT.DING AOE
O p Ibeiby�Nor dem u.canurucllae lenNng mommy fa Ne pmfam.raed -
Z Ne wait fm which Nu pamr u iuued(Ss 3()9],Civ.C)
t:. lassie/e Name
CYi ? Lmdcr.Addimn
W A I mllfy Nu I have rod Nu.pplicaran ioe anal mote Nbe.bove inram.um Is
d a.I.guom
e Io cply aiN all cuM roo
r amy mNuaea and v.•lavg t
,relatino
7 Z care
WBdiy cwemvooa,and hereby awhoos mpmseutivn of Nu city meoee,opn Ne
V Q abovo-mgniad". Y for Iupembn,epees.
(K•e).pee to a.te,iodeamify anal nap bannlean the City of Cupeoiro.punt
O () nadlitiu,jdgeema,ev.0 wd capms wtib may in any way anme siaiw uitl City
S m gagre9agam d Ce gwdog or Rd.permiL
_ APPLICANT UNDERSTANDS AND WI U,COMPLY WITH A LL NON-POINT
V Z 6URCF. .GUTATION&
mere dA /
n,
pplicanvCowama ane
B
HAl.ARDOl1S MAIERIAIS DLSCLOSURE
WIIIW appkannafmlue Wilding¢ulpntnagan..elg haaotd mbnrial Re-roofs
as deflect by Ne Copmtitw Ms.ei vl Code•Chapm 9.1;mod Ne Health and Sorely
Code. 25532(.)' Type of Roof
El Yes
Will dle.wicmtarfuxe Wiwi,occident sae mp,ipme,Im dgvigm whish All roofs shall be inspected prior to any roofing, material being
g thaot aakennonsmanta..defladbythe B,a, r AuQuwtyManalpmem installed. If a roof is installed without first obtaining an inspection
❑Ye
LAVI� I a vee to remove all new materials for inspection. Applicant
INvg mead Ng h.mdou mnmWlegWmnevavdm Ch.pm 695dlbecali- understands and will comply with all non point source regulations.
(arch NeIN R Safety Cade,5 W i]5503.U533 and 25536.1 wdvemd Nal if de
WiMmg dm pal cu.na]y eic.eupl,dm h is In,2+Ponobinq to &y be..pw
d which Imm W InI n ismotsre ar. M
0 Signature of Applicant Date
ng.m.wtat»aa year Dare
All roof coverings to be Class"B"or better
OFFICE