00020184 CITY OF CUPERTINO NO.
III BUILDING DIVISION PERMIT CONTRACTO&INFORMA'TION:' O 0O a 0 �J
BMWING ADDRESS: U
/'7 /r �P rear _ Masonr"J Xi) C SANRARY NO, APPLICATION SUB C7AL DATE
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CIIITECT/ENOINIiIiR - BUIDING PERMrr INFO
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z O'_^= Um itut Is CONTRA uni Woci;MnON .
4v E IIKrt )(00)' Ihu1 lico®dImenpmYi.lOpdc>,.p«9itcyl ck6 Job Description
r:C wilhnr.,m00,MDivia^Jdd,cBmim.utlRofaiamCam,tdmYecvrcu hl mile
N run ram W enc
Re atr c p
s o�� UcnscGau Y 1V Uc.. 62339"7 P � . t rorvt S oto ccl�e vr- . G!�
a_nn Contralm I
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t u.O 5 ARCHRECrS DECLVtATION - '
F 1 ondenurW mY Plw.IuO b<umd o pubic recnd. '
c O Licmcd Pm ai«W '
u�i R 15 OWNM-BUaDPR OF.CVIRATION
C r .I by tRbm Ihu I am neap)from Ne Coots«^!.U..I� for the .
E e a follaiw buewort(S yim 7()3 13,llimn .wE P.ofesuaR.Cade:A,city,or enemy
p 3 whkh mryun•pm""b`�°""•w"'inminw,matub,«rtp.ir teY.wctae Sq: Ft. Floor Area Q�� / Valuation
p.amib iuuur<.Wo to ccmohe Wptia'.^rf«wch PaW.ufik rtui .unomr _ rel b
Ibn hculinoscd p.num bdK pmvhl«ud NCCmu.nuY.11«astaw(Ch.pler9 '
),c.1 (.iir°) of APN Number - Occupancy Type
Wa he u neap Nweapp tM tlK Wu.f«dK cui cxolgti o a civil
Hv1Yia d ,. p y `J p
sada iomfiydy cicl r«.�mR.lrof«I,ur.PPli�n b.aHlPn,hya 3 7J`
ea mmc ILm Rw hlvdted ml W.
❑Ln.wnndlheQaPn.y.«mremw^rn+w�.w.�nmevekem�n..u� - Required Inspections
wdl mthcoo Cool, ,c ComuII^IIaL aoReretl f«tW(Sattoto Rmcn
w pwewan.Calc:The cmvalle'i Lianm law e�^a wNr toto awae d
prnPcrtY who build.a io Itu dtacb t and who doa wch work or
a d for
hit own empl«Yen.Ilmvidd nut turd Ilpptotcam trt vaI u.. ...«oRaed f« -
de.If,howK.v,dK Aildie5 afmpmcnKntk Wdvebin orc yeudm�luim dK _
ovea.AtiWn w111 have Ur burden d pmMw dw Ile did mr bulW«impmw(«pIv- - '
poKd Wn). ' ..
❑ 'ft of Nc pr^pc 'B.cclpu"c^arariw ccveiis comri'mic.
cccn�Icos to
em.tlu dK Pminl pply Toa,Rndpa r p RMn.lm.Code:)The CmRabft
...'•law am.at.ppy b Yl aware d ptwatr who IudA«imcb..-,�..ld .
MLO®Iaal.fa oltll pmjecu wiN.ccao-tmar(s)IwKUN Pla.umt b�Cawaclar'.
Ison exempt.M Src. .BkPCf«tN.tmoe
Dwxr �K
WORlfnt'S COMPENjm,oci DEthe fd nON -
IlKrrby.IRrm aMm pnwy arpafory me of uK rdlo»;w declutew:
LJ Ihrve and will m.icuin.ccm0o¢orc«c^v b.eB-m.urc r«wwtcl.comPee. - din,a _
tion.u poHd,b f«by Satin 3100 d the lab«Cods,f«w peA«ounce d tlK'
ak f«which 11 mi pai.'v.ued.
JC'IODdrS'lTaYbloirC�ade./h"iV^Ibcperf«,m.«rcipeNsacwort f«vh�kL Jri.pmnh lsim_
Myw (. oWVn
4 Pdcy Nrd -
CEBIIFICATE OF EXESWITON FROM WORRPJIS'
COMPENSATION INSURANCE ,
(Thi.calm«d oa W ccr^,k ifncc pemn,u faoochu milt.13100) ,
' abl „
I m4(y dw le the perfwmaae ddK wvk r«witich lhupemtil i.i.e�d.I"I
m mnW any Penamavy m.e�wubbavlK rubjew btlK W'wtm'Compco-
W im law.dGlBank.Due
APP kuu
NOHCE TO ct to tiCANT:If.Com rWliw di.C«dfuve d EA,cc c v,Ya of mcc t
hemmc con,b rhe WMef.Compenwbe pirmt n d die labor Cade.. mw
faWwidl comply wilb ulr.T ptoHuon.a Ni.peneil..•I be dumd rtvotrd. ..,
Z CONSTRUCTION(ENDING AGENCY
'IIIc wan r«we,efr leena.caawtrem lme!nY.r rf«ele l=,rmn.l�a - .
pomp i,iwKa(sat Jo9'r,a..c.J
Iaedel.Nude
lanai AdNc.r
Ccl 1 mtif,dw 1 htvc Ind kii Wpllc.lion tM uue Ilw Ne teow IMoruudm 1. '
6. coral.I tgm<b comply Mtih till trey.m cam,adman ud uta kw,rthtinR w
Z b Wiw coo.uwcu^n.ecl hvicey iroa rtptnemallvn of due city b enla apaa Ne .
tbow�mmiollcle to io fa inp fy plvpa.n.
1w floc,
V 4.biliur.�ludDr amus ud e.Pm.e which myi^+^Y Ylrvue+Nml viol CnY
jr In PPIIC «C NIDK 511r14nj Of dli] WIU, y
4C^�. APPLICANT UNO- A AND WIIJ,COMRY WITH AII.NONPOIM
I.; SOURCE REGUI r
Z__2PO�
SiS ofA Due
HI F UOIfS MATERIALS DISCIASURE
will the tpplirammfmoc I,o,wyocmpit—a htMkhawda.mu«itl Re-roofs .
n defil l by the Cupertino Muoicip.l Code.Chapter 9.1;ten the HvtIN td Susty '
core.satma z55324)? Type of Roof
❑Ye. ❑No
All roofs shall be inspected prior to any roofing material being
ormt u< �defimidbydKB.yArt.A QtolhyM..S m m installed. If a roof is Installed without first obtaining an inspection
El Y. No I agree to remove all new materials for inspection. Applicant
understands and will comply with all non-point source regulations.
I.IW h St Safety Code,Secliao 15505,25 ]tool 255M.I vndu.Imd Uw If dK �
AliWiwdonnwcarnlly hews otm,Wlh' yrnpowbllitybaOfYlh ottopml .
'hvem mu prior u.ua«e ofaCatifa+KdOivpvvry.
Signature ofApplicant '.' Date .
Due ,
• .• All roof coverings to be Class"B"or better
OFMCE