09050159 (2) CUP
CITYLOFNc vEis oNyO PERVIIT 4,Q R�'1CTQR4NPOR MATI
s. #;Par!,.:;tr2u�ryap!�T�tiwr,'�.r)&abr. 1s�=x!sn •'
BUIIDINO ADDRESS: PERMIT NO.
20640 STEVENS CREEK BLVD TBD — TO BE DETERMINED
OWNER'S NAME PERMIT ISSUE DATE
PHONE S A 2 9 9 9 CONTROL.NO.
ARCHIrECr/FNGINEER: BUILDING PERMM INFO
BLDG EL.ECr PLUMB - MECH
0 —
rtp0 LICENSED CONTRACTORS DECLARATION lob Description
m G 1 bacby afnrm Nu 1 w li-. Mdur pmvisons of Ch.'.9(mmmrxing
U with Sreuot70(10)ofDivuion 3 of Ne Business and Rofessimu Code,and my Ike=is
�% infullf. Mdcrn� 4rs '7� 8p CHANNEL LETTER SIGN ,
i3 F Lice en Clan C. `f Lk.M
f-C own Contractor S
W ARCHn=S DECLARATI N
u1 uadervand my plans still he uMd as Public cords
nD
u.1 Licensed Profctional '
�
{ OWNER-BUILDER DECUBATION
I hereby vMm,that i am acmpt from the CEmirac e'.License Law for tic
t O o following mason(Semon 7031.5.Business and Pmfeau nd Code:Avy city err roomy
which rtpWres•Permit m C.nstrmet alter,improve%dcmolidt or rtpcfr any suunme
Izi priamiu Eauarcc.also rtquira Ne applicant for....h permitm Oic;signal summcnt
❑� Nukuliansd PorsmntNtk pvvivooa of the Conuv:tar'n Id¢mmm Law([hapter9 Sq.FL Floor Area Valuation
(commencing with Section 7000)of Divnian 3 of the Business and Preload u Code)or
I '3 2 Out he Ia eawpt thcrtfrom and the baser for the alleged camolvdoa Any violation of $2000
Section 1031.5 by arty appiiamfor a Permit mbjeces the ap &ML m a Civil Penalty of APN Number Occupancy Type
out mnrtthan f.hundred doll.ISM 32610060 .40
I,uownu of O¢prvpvty.err my wPloyen with wgcuNe'v sok sampermsa0on,
will do the wort and the swct.u notietetdcd or offend for sale(Sec.70 U.BOO. Required Inspections
and Profeensiau Code:Tie Conte notd a I m^" taw dna ort aPp1Y m an owner a q P
pmpeny who Wildsor ho rove;then. mend wM dvusuN work himself;through hu -'
awn employna,provided that such impmvimeau are nut inmera ed aoResed forme IL
hawcvcr.Ne building or Improvement is sold whit.one 1.of enmpledon,Ne owner-
Wilder ove the N
will lc bucn of proving that k did not build or improve for puipotc of
0 1,ea owner of the property.w cedudvdy conoareing with Bensed ennuacws Ed
cormmm de Project(Sec.706,1.Business and Prorctuw Code)The Come.Li-
cense Law dao not appy on an owner of Property who builds or intmom demon,and
who mnuaeu for such projeeu with acwvww(s)thorned Pensuna m one Convano's
Licc.Law. ,
O l w exempt under Soc. .BB P C for Nis main
Owner Dau
WORKERS COMPENSATION DECLARATION
I thereby aQm under pendty of perjury.of the following dW arationc
011%...and will maintain a CcniBenu of Consent 1.roti-insurt far WakeYsCompcn-
nation,ea Provided for by Scotian 3700 of the Labor Code.for Ne pre...of the
work for which that Permit u leaned.
0 1 have W wfli maintain WorkcYs Compenadom I..,as tcgoimd by Sea-
3700often,Labor,Code.for the Perferner x of the wak fa which Nu Permit u Earned
My WorkeY °motion lncmutc arta and Polity number ere: �7
Grtier. E0.N 1g V,Lr�Cl.. Policy No.: tAj �IN 00 &�/ g 0 ?-
CERTIFICATE OF EKFld PILON FROM WORKERS'
-"- -COMPENAT70N INSURANCE
(This Qcsion�d ort k enmplevd if tk Permit hifa ore hundtcd dernaer(51007
or lett)
I anifv Net In the Perform.of tk wA for which Nu parnit fe issued.l Mail era
cmPlry any perm.in anY manrur ro u m baomc subject m Ne Wachner'Compew0an
Laws of Califomia.Dam
Applin.
NDTICE TO APPLBCANT:Il afar making this Ccrvfm ew of Eacmptiom,you sbould
become wbjm m the Wanket's Compensation provision of the labor Codc,you mtm
Z
forthwith Copy with amen ryovis oro or Nis permit small k deemed mwtrIl
LO CONST7tUCTION LENDING AGENCY
-v > Ihmvby.form that chert is a ecatemmimt lendingagency for derpemamm.of
the work for which Nis permit u issued(Ser.3097,Civ.C.)
t7 F; Lem ices Name
I Z Lender's Addmea
,J O 1 Certify that I have mad this application Mal mm that the above infor aim U
F' Corea I agree to Comply with all sty and county mdimen a aM sum laws Hating m
V building c.muncti..,and bacbyaoNaiae rtp.madva of Nu city to enmrupon tic
r G "have-mentioned Property for impecdon puq=&
(We)agree to ave,indemnify and keep ham0eea the City of Cupertino against
liabilidcjodgmmmu.cosu and capm-which may in MY way..againstsaid Clty
;J-.Z. in.cme'..17theganti ofthu pmmL _ _ _ _
APPLICANT UNDER Sr AND WILL COMPLY WITH ALL NON-POlvf -1 sued Date2.2 oG
SOURCE REGULAT70NS ` J/
S/27 0 Re-roofs -�—�
Signature of AWlicMVConGZW-r m Dam
H ROOUS MATFRIALS DISCLOSURE Type of Roof
Will the Vpl ant orfuture building omMore e w handle harardom material
aa dfined by the Cupertino Municipal Code.Chapter 9.12•aM the Health and Safety
Code.Senian 255324)7 All roofs shall be inspected prior to any roofing material being installed.
❑yes
If a roof is installed without first obtaining.an inspection,I agree to remove
Will the applicant or future building occupant use equipment or denim which
..it human.airc..inanu defined!by the Bay Area Air Quality Mamugmcnt all new materials for inspection.
DEorin7
❑Yu No
I have mad the havdma maen'alsrtquieemcnu uMerChaimmr495 ofdrUlifa-
nix HealNBSafmyCaM,Soctom255115.25333 w12553<.I undersunW dutilthe Wilding
docs wt c 0Y hvw•um mt that It u my rtspomibility to nodry the occupant of the
roquinmcta Coro k ctp<iormisra.enancmtireaeof n. Signature of Applicant Date
All roof coverings to be Class'A"or better
Owner ca 0tryormed agent �—
L CITY OF CUPERTINO
- ' SIGN
CITY OF
J, CUPEkTINO PERMIT APPLICATION FORM q
APN # Date:
3ocav , ac, �-- 2 7 - ° g
Building Address: (�
�UG �O J '�P✓'PvS` �yP��L �/v�
Mailing Address (if different from building address):
Owner's Name: Phone #:
440 - 9 < -(. ' OS 3�
Contractor: (� Phone #:
?SLov ,4 J Fax #:
Contractor License #: Cupertino Business License #:
-� 59 3 0
Contact: Phone #:
Fax #:
Building Permit Info:
Bldg Elect ❑/ Monument ❑ Mounted on Building '
Residential Commercial
Job Description: / n
-ke
Valuation (cost of project):
Project Size: Express Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the sheet index.
Revised 01/07/09