00020035 (2) CITY QF CUPERTINO PP.RMITNO.
BUnbtt9G DIVISION PERMIT CONTRACTOR INFORMATION: 0 D O 20 0 3 S
BUILDINGADDR S: 0/),5F
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/' n (�)�•1✓/1�(,(//I/ G11L �/f7/�C/�J/µ/1GfI/K/J� y �NC• SANRARY NO. APPLI%TION SI$�DAIE
O ' ?R;SNAME' li / /bV Na"//O////L�1�4 IfY9. 2 ar)�
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ARC M;,CT/SGINCER Csi,J293-Zo/f- GUIDING PERh1R INIn
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o°z I1�.1>n Did 3 l Boo d«f�;.iW.da�oele. Job Description
F_C wimseemnzmo)davwm 3orme lfwem.ed Frafmmecade.Wmtiee
oa thhllr«e .�
3`a Dau Cotmaw
t ty O, live;
"t F.CTS DECI.ARAnON
I.m,.wd mr W.m d,.lue..ea..wtlic
Liceved wiorW
OWNER-BUB.DF.R DECLARATION
F Z I beteby M.tial I am eumP tram the for the
D following roan.(Sc7lon'l031.5.Buvnes W Rafedm.Cade An dry«°wary
awhin oe,h .perm,to oo m alrc,imPate.dm,dwt.or tep.l W emrmrt Sq. Ft. Floor Area Valu�(ion
PA Wlb iuuacZ.al.o rtgo thc.pplicw foraoch pmW file le 08*" ubnaf (J
tibia W u lien.ed wmtm,to the pmri.i«u of the Conuanaf.Lrrnec"w(Chapter 9
(mronwoa.t with Satiap'l000)dl)ty as 3 ofthe Built W Ptofe.iuo.Cade)or
not,he u e.eW thnefmm W the besie for the wegm euatptlw.Any w+dwoa ar APN Number _ Occupancy Type
Sctor RDI.5 by ury.pplicam for a petmlt wbj u the pplfuu to a civil pe.lryd
a«more tw nae I,. ,mlwa(55th°).
❑I.uawaadmep,apenr.«mY�ad�w.wimw.g«emevewewa�e.�daa. Required Inspections
will do Nc wa k,soothe mucme it not ineoded«oHemd for tele(Sc.l ,Budmt
sod Pdeulau�Ib,eaeuveoW,I.loewe U� does ml apply to N«.rce d
pia ,who buil.or impwe.tbeot o tot!who den acb work hinnelf or d.,h
his own employee,PavMed the.tech itgwo,caeat tee oat ieetded«offered f«
eat.It howc v,de builiag oriat,,mctnem b edd within we yea of wagletion,the
owmeaboildcr will one de buNe dproving the he did not build«ii p of«par-
P.e
❑I.u owoor of de property,w cclaiMY cmaadny with liemed emtraetan W _
oo tUw projet(Soc.' ,Bu.ines sio,l uim.Cade:)nteC«uactaY.O-
m "w clan not.pPIY to m woee of o wba buJN«imft thrrtaa,W
who mine:,.f«ew h Pojecu with.ewuactvf.)licem 1 wnum W the Cowrblc
emc law. /
❑loo e.emRuoOt Sec. .Bk PCf«thi.rmm
WORImt'S COMPENSATION DE
I h rehy What mfr proal,,of fe+hry ow of the folbwwg delteuiam:
❑Ih.. "will m.awn\CertlftnecdCamra b.elf.lmuie(«WotleeY.Cmtpm
W bre PovSdM fee by Sem:m 3]00 the L.
of boe Code,f«toe m
petforttue of the
war which thu Pm^h le
ut,ed.
iE=hvrc W will muouin Wtrtd.Comprmtelon lmmaace.u requ by Scum
]!(IOMdwihc L.(E�«opC�omoe../or Jioo��su�peermfe«�vune d ibe wart f�«umvyhl�cbeyJw pvmil imM.
Cur le('+,�D1T.A//1mxl Po No /TA)KWp
(MIU11 GTE OF P.XFMPIION FROM WORKERS'
COMPENSATION INSURANCE
frlJa ceuion tt«dttor hert.egletea it peooe,M loewe bu>,thW dellen(SIM) -
«lee&)
I mnify the w the perbrm.ace ofthe wale for which Nie pet uAu IibaB
tv employ anY porn in any minora m u to b wbjentothe WaM1en'C«nPa-
W:on1�wtdC.hfari Dec
App atnt
NOTICE TO APPLIGNT:If..ft,r m.Wtq tw.CeniGr.te of 2a nuc ,yoo dbdd
buvbs PAb to the Wooer's Coe,ensstlan pmWtiau d the Mbar Code.you amn
fvthwlihC o ty with eeh Mm .lam«tbb pend,dWl be deemed rt,akad
CONSntU ON LENDING AGENCY
Q Ihveby.Rum thv dart i..compucdm kith, tevcy for the petftmueord
the work for.'hich Uw pori u laird(S¢wt.Civ.C.)
I<ttd[le N.me
W 1 certify tote 1 b.vc two the,"Otioe.nd amee thet fl,c ve lafononwt 1.
z c«,rct.I.gee to Imply wlth.0 city W monry adiaure W tate law.t n to
balldmg comtrvnion.end h by autheriee rapc¢nutive a this cit,W etpc upm the
C.7 .bo,e.mmtbnd PW-,,Y f«-Wert oo
F Iiabibti(W,e).,iW..a� ry�iWlekawhumleu the City d Cupertiwa taut
j
U Penes yw.Y. iii.0 Ch, .
} [s: m cm.cgotec d tie Ysodtp of thu pcm t.
F_ APR.IC UNDERhTANE7S AND WILL COMPLY WITH ALL NON-POINT
U .Z SOURCE REGU TIONS
Slgnmm of App Wc,« ate •�f� 1
SOUS MATEftIALS DISCLOSURE
wul the «faire buiWittg aawp.a tart«Iwdk n,mdaa.etwrnal Re-roofs
u defie by the Mu I Code.Cb. 9.11,W de Het0th incl Safety
cine•sedan 25s3z1o, Type of Roof
0y.
Wig Ito appL...tcefmate Wiv,in awPat me Nwonr„W denim whi b All roofs shall be inspected prior to any roofing material being
eMt oossur ;mine..&�br,t[MyA Ai�IryM� installed. If a roof is installed without first obtaining an inspection
agree to remove all new materials for inspection. Applicant
❑Ye
I z,eteddrb.oA ,meeml.,wtdrtnm�.a;tde,Cie t 69Ydthe C.Ii understands and will comply with all non point source regulations.
fano Belth R Safety Code,Segiom 23505.25533 W 2"U.1 oocltet.ad,bat If the /y
hvldmgdoe m calm y bu<.tarot.thn h u my rmpom ffiy to nasty the omtp.a /I V
of the teen whicbmaebeme,pnubiw.rce daCeroftnted L/
Signature of cant Date
Owreroran - .gear u< ,
All roof coverings to be Class•B•'or better
OFFICE