00030122 C
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Q Jr3reoRMrr NO.
UIoc iNPERMIT CONTRACTOR INFORMATION:
r2c2—
BUILDING ADDRESSDSANRARY NO. ncAnON SoULB«
f4
DAT
NER'. ME
ovc T.re ��97
BUMING PERhffr INTO
{POO
CS<L
G«
IJCENSPD fON1RAClnR'SDECIABATION
Y.°y— I Meb .1Me tkt I.m li d milt
oi_ r w.;.iantaC3,.pnleananm=ing 9JobDescri tion
wish$ um 10W)aDiritiw3af,k Bv,Im,.nd RofedamCode.and my R«we4 Pir/OV[. ✓� d�L
71,
�� unl�IrataE�.meR��� Is.1 S07Sy3 Sn✓/ it// / Coe /'f
5s ,
DECL�Goarh1fn11 SAF asyr �0„�10, roof
��.$5 ARcxrfecls DELURAndN
v��� IutWntutN mY DI.m JWlkwed to pblk rtad,
a�° ucemed Ihora,bul .
A' 1 OWNER-BIRt.M fr D dine C
t Z< 1 busby Winn mu I 5e.unto from tk Coeu Coo licnue taw co the S-s
+d ❑ fdlo.ing wan.(Sactkn ttll I.S.Bmncu aril Pmfea,itm Cady Any m«
ash w°kt'">„'I'«'"Q'"'m�""'°«•'e�.`•°"""i'b•«"P�'�,''°"'°'< Sq. Ft. FloorArea Valuation
pi«toN4 6mmm tk tpplkam f«mch Pumil on fde.tiprd,ut®sm
,lm k u lkeuNfoowmI to the Povi,ioru a tk Coeu<ml,Ii -law(CL."9 Soo.oO
(catmamcln,wilt SMI®7000)of Divitim 3 of tk 15ulem and Pmfn,lau Code)or
mnkni, , tl e.wdte him,for me.u.nd a„"U.,Art,.;armor of APN Number ( Occu ancy Type
Sarltn 10315 by my.pplkmt for aprmdt wbiom de.,,Itc a to.bull peaky of /lp 33 Q�� -5-in,
m`
.n mato dun r mmmcd en
doll (s5ao).
p 1• ft ni oron,entam.wtln .ndta.wk .pinion Required Inspection
wen dame tk i,rotintended«aretee r« ( toow.l3uuneof
.ab M « CookThhn Coon«'. no, 0,to m awnor of -
proputy wk buiN.« tlti tk i ud who do«,«h wart him,or
tis own emplgm,p tficis r ii wrh Imp iiimi u K not in,mhd«oRe,td f«
uk.If,hawc .111ovuiWiry«i,tptnemm,it,ah dW non
WWori omWniot.t,
ow«r-bwWn wlll Nw tk buNm a p,otin,thtl k did n«bi3d«irtpme f«pm- t
❑L uoven ofinepoPnsr,mi,ntai,,”c omni co 4amad orS -
cc,ltnwtt me pmlet Lpply'rt N..Bu,innt.M Ptdin,bawior)Tk Cn nono,m,i
uroetawdmmt,ii mm ovenmptapmyrhoboildt ariini dtveore utd /Y
who cwuacu(«ooh palcu vim.mnrml«I,Ilkutad puw.tu to tk Canv.,mtt / .
licm,e lay.
❑Imot. endo Sec. .BhPCf«mittea,® .�
Owner D.0
WORKER'S COMPENSATION DECI�TION
1lctbY dM1rn®hr po.Ry or Pnluy ten of tk folwln,decWuion,:
Ili vc.,tl will mtisuly.CeNfwn aCmmnmr3f-u,mer«W«trYtCmTeo-
u,iot.u lf«by Section 3tt a l lab«Code,I«11o,puf«mmce d,k
f«which III.pearl,u
1 ivued.
kwe toil will wivuin Warta',Catpvuulon 1.u ttgnvd by Semon
1W oftk lab«Code,f«me peHmwNe alkw for
�.w�i ttthisp ii 1,Uomi.
My W«tri, nlewr.rce Po Nrn /Yet7d��
CPArIFlCA .�P] PITON FROM WORKERS'
COMPENSATION INSURANCE
mii„ctim n«d tot kom pi tnd I,k pnmi,u for.Mm&ed"I.n 15100) '
or n,)
I cenify mu in tk perf«n.xe a me wort for h hmi,pnmt 6wIDull
not employ my Annan b my trams w u to In v nmjm to Inc W«tn.C�
,.tion law,of Calif.D.0
Applk.w
NOTICE TO APPLICANT:If,.fkr tntiry N,Catif^•t,of E.Vt you should
been,tm3«t b tk WC«ep t povubm li do tabor Cade. muu
l«mWm conWly vim wx1t ch ptovl.iwt or«mi,prtN,th.11 k Jmmtl revoked..
CONSTRUC'OON LENDING AGENCY
O Q Ik y. .isi,then 4. lvdmy.gc yf«de lafonvnxa
Z die w«t r«whkh th;.wenn i,i.v.il(se.3091,ci..c.l
t.., 4 Irndelt N.
C4 7 Tridil,Addrtsn
Ls7 Q I anify twl I l roil mi."ltntvt um ons tkt tk.bovs id..u _
= z mrtct.I.g,c tot Ply with 01 City mKi corny«dln. 9mil.u,t Vw 01mogm
Wittlins.nowit.ion,
U O .kve mewwtmptvpettnmk ion pcp vnautis caro eaw tenon rat
f. I%).p«to eve.Ind fy"kup hannlc,ran City of Cupnmo gmtst
-O rJ liabiliti pd,nmu•mu,nW i,. m vIna mar in my w.y t«..,.m,t,.W CJry .
L in mntqut«cadogrmritDS NILwmlt.
_ APPLICANT UNDFASfANDSAND WILT.CUMR.Y WIn1ALLNON-POINT
t.1 Z SOURC i EC , r1UNS
aAppl' UCn or Due
HATARDOUS MATERIALS DISCLOSURE
Wlnmtlnli t«Ntmnliomn—rontntnt,w Re-roofs
u definM by the Cupmlm Munieipl Cods,C ti to 9.11,and do HeM m,1 S.fny
Cods iorin531107 Type of Roof
❑Yea
Will tk.pPlkmt«funuv Wilty ,« t,,mt we e,ip or de„iat white All roofs shall be inspected prior to any roofing material being
�notaw .•m byib,l ..Akaa.ImMm installed. If a roof is installed without first obtaining an inspection
'1w;n1 I agree to remove all new materials for inspection. Applicant .
❑Yn No d
Ikv<and do huaNw,nwm.p tequirttrcnu atda Chtpa69S a do Cl un erstands nd will comply with all non point so rce regulations.
f«vi.RnW k S.fay Code,Soniaa 15505.u333 and 25534.1 andntu>b thn if tk
tuildin,don oa asmdy kvt.t .ynt I i,ny,nponJhiliry to notify de orn�m, Fa/ Da
dtlrt whkh tet prow mount d.0 a prey.
Signature of A icant Date
_ or wharf nt Dim
All roof coverings to be Class"B"or better
OFFICE
�j
CITY OF CUPERTINO - PERMrr No.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:, �-
BUILDING ADDRLSS: �J A/nn 'A�Le T/ 0a3 D�.?.2 /A/, tf
:=:J;10/0,5- �/—C AYe /Vr� V G if "o" , SANRARYNO. A�C ONS MO7AL DA
TE
OWN AMB: / �_,..[ p� ID2/ 0
P 'y�n7fOnt 7'14 J�✓! .7Y'�n aJ Nrc CON'IxGL»
�1 ro?7 f r e, rA 9r/�9
AAiCHrYtCTMNGINIM.R - BULDMG PURMRINPo _ y`y t
03
z�
�a9�
Z O yLICPNIRACIOR's DELl.1RAnON
oz— 1p4•^Y'' ^'^"l3aro l��1, .mks acro.pt"9lf.ror s
�C xO,.r9�5'' ,m"mmns—ar,Iarm.bmen.m',m0000ene)e o<y.�p,�l.s dwl he.cromm`.•.`wI�hlirrCmOr�dr lr,c�a..�r�rYl ..i. �4/t/,e_� / G Job D
obDes/crTip/!t!io�n
rdAXL.1lTDECRN C
ITO/Do?T�.
c/
°° IJcanW _
�S bacbOWNER.Hul � DFCI , KTION D
I y• m fartA.,I.uemp,hm nits, m
Ctr.c,rd.Lic lar is IM
❑ foBwin rum.lSatim r 31.3.Bimoe.W Prc(u,iom Gde:Airy up s,n®ly
whkh rtgWrp•perch m caouvc4 Wer.Impoe,demtl W,s rcpm arty,bucthrc
s— prioir. . ..Irorrsrr.the.ppir.mSq. Ft, Floor Area Valuation
that he it Ib porwu„Io me pmai.brnof th Canv.ctN,Cumin law,CWpc 9
(� nwimseemnr000)aaw.wn3am.BusinesssnJi ma.iaa•Ceer)a soo'ni
U
bins,. AP Number OccuD`�c T
that ho u evuipr Jcofmrn d ft los the lcyet m Ary r'iN•tlsi a 3 3 0 / y y
ScNm'!(IJ136Y.nY•pPBonrfa.pcimi,.objcU Jr.ppl'rnv m.cinl pm.irya 'T/
oo,nrne m.n fl a bmtmed(Iolm.uwo).
❑1•„o.�amcmap�rramrenq�eewimw•s<,..meirra.�rnpewe�. Required tnspecti
�in m we colo:
Th, ami. o,im ..Lsrde re o tsppl wu.emia:a
,nd PmfnWm cam:Tie cmpan,ar:came lar can na,.pply to m awtte a
his own who bdW.pr B 'I'Iherem,artd rho don Wino tint hinxV s, fo,
his own cmDby he provided r i wrh i�.o,emna thin not finer at a off�f c
r.b.If, U$erw,dehtuWibsIon of vesVn di,tatNyear acmthfair me
warhuilder will ha,c Ili buNat a pmWtq Wn he db trM bead a ivgo,e far wr-
paeaelt.).
toot a t ft f or the pnopety,,B Aintis"cauv.cdnl rich�mnv.ctua m
tnrrl ctpmjsl(Sa'. so Bu,inof p wboIn{Cade:)INe.thtoon.an-
tto.e lar doth on"4"..n owe of PrupenY vM buJM a itrmravn ticeao,and /__
rho covv.cl,fs,vch projece wllh•coetr•cls(.)Ecmvd pw.u.n,m Be Caaratm', (/
[]❑Imo camtptaodn 5«. ,BAPCfs thi,ream - Q
0
Ore Dur
WGRIGlCOMPENSATION DECLARATION
1bcreby.Rm
rands Penalty of a Coos aacathe( In,d soo:
1 bw.rtl will ix byp.Ca,i 3rn aCoomlso rCtlfmcfsWQteY.Csopen-
t,'kf r that
fm by Swim lIW a the tabor Code,fm tl,c perfsmeee of Ile
ryrk for s,,I dti.penal i,uvrW.
h.K•ed will iminuin Watch C ofthbe work
fo.m,a r J,t by$cube
110alhc labor Codc,for Be psfmm.ncx aIle wat fvs�rr�MpchycW,pennil Is I..oed
No.:
MY Wats' von urate vN Polo
tinier, c Polity .:
RSIFICAIEOP XEMPnON Flbom WORIauts.
CnMPEN3 jf LA
INS NCE
.fon
(TIe rccnvn osd m becanp4ed IfNe pmoe v fwox bmheA ddlsi.(1100)
Q u0
Ioy mytbuin Jin pefomen aNe wkror oich to
Wli•i, 'Cd of
rtol employ thtY pews 11 Ds mover m e m bs mbjecr ro Nc wsken'Cor�cn.
,ubtt,sn, CW(amie Dae
NOTlk%
NOnCETT)APPUoW If,.form.Idttlthio Cuuf.ad Lsbo,,Cn,I. o
hesune w P to Ne Wah n C r pmviriooa a nbo labs Cade.yw rmm
- faMrlth ranplY tial,uch prod,ion,slhia permit YuB be dcmed rcvoted.
CONMUCTION LENUDIGAGBNCY
O 0 I heeby afrum thin dtnc 4.cawtutim lwdM Vcney for Jin Psf.or
Z de tisk for which this psrvit 1t uosol(S w9l.Cl,C.)
Ledefr Nave
Sc
I Isodrimtlfy A t
Liz ^G, fY tlw I ply tpd all
O application lad.ulc this the.ho,c mfineuion i,
cnrrect.I OM mcomply with y c1lY W nl,s,,s orcnsiioaof IN, t,t laws rrW t o
C boJdinQ camvucdai,.ed lLot awMriacmpcacntatirs athi,city toctvu upmW .
U O .macroemdavcd prapstY fs irvitnify pspo,c.
(We)m" e.indnem(y.ndkup b.y in any ft City aCapatinoy City
�O'• U B.bilhica.lvdNene•cova.rtd capcou rhich myin.vY raYaNue.ryw,.W City
h �" 1AWLI UND RSr"DS AND WILL COMMYWIT}IALL NON-PoOINf
Z 7 9
U `u�RP�tr nnuy f� /' /.t/!• /
HAZARDOUS MAT LkI DISCLOSURE
Will the.pplinnt a future Wowi,mrnp ,ta s betAe heudpu meerial Re-roofs
u defietel by tb Clrpetivo Mw ipsl Cade.Cow.9.1Z l o l rho Hnhh od Sooty
coee.srew 532(.)? �/ Type of Roof
[3y. "?
Will the.ppliwu or N.WiAinRarcupen wbich All roofs shall be.inspected prior to any roofing material being
lhusinin isoc•c••ro:n-•+•umoundbythero
B•yAAirQollrym
Ms,, c installed. If a roof is installed without first obtaining an inspection
" " I a ree to remove all new materials for inspection. Applicant
❑YQ No
h . ,,� b.ado, m� ,,imine derh�mb9 a� u un sta s and will11 comply with all non point source regulations.
forth.Ibhh d S.fery Cade,Sactisu 23303.]SSJ)nd 233JC.I undnn.otl the If Ile •
bltlWiy don csnntly lis c.,crus.Na,hi,mY rc+pomibilkymeotify Ne accupam� ..///GCC///. ////`oui `�� Op
orcin rept t..,. t,;,w.�d.c a
ow�aw 4?. .( •(/4a� D Signature of Kpillicant Date
All roof coverings to be Class"B"or better
OFFICE