05010180 CITY OF CUPERTINO s{3'
BUILDING DIVISION PERMIT ACU,, RACI ORTNFORMATTaN C
BUILDING ADDRESS: PERMIT NO.05010180
10489 SCENIC RLVD
OWNER'S NAME: PERMIT ISSUE DATE
Aga& DAREN SHUE 07/21/2005
g; SANITARY NO. CONTROL NO.
ARCHITECryENGIKEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
o I� o t�
�0o LICENSED CONTRACTOR'S DECLARATION Job Description
�i 1 huroby a0bm Met 1 am licensed under provWom of Caper 9(commencing
Lh Sectio,70B0)off) cion ofthc Budneusod Profcaaom Code.md myliceuaela
DMi iLcllfarce�deffett � » 2 �_ SFDWL-2 STORY (53051 LIVING)
&g- Conrsttmr GARAGE/6301 BASEMENT 14401
AacxlTecrs DEeu
U u isun y plana thall W used ss publle oN+
G Licensed Professional
OWNER-BUILDER DECLARATION /�
1 touchy aRrm Wm Thal 1 am exempt Me Contractors License Law for the
0 O es m fallowing mason.(Section 713 I.S.Businma and Profussium Code:Any,city or county
$E which requira Permit construct alter.borrow,demolish.Anan
. mpsir y souttum
—i� prior ut is issuance,alas mquima Mc.pplicant f"arch permit to file a Signed matemenl
< thou a u liceved i uyrvem m Me rmviaiona of the Cohuacmrl lhenso taw(Charley 9 I I Val"=�0 0 0
Xt51 (comon cies withswa.7000)aDi.on3offt0W..ditfesalmm Code).
— Nu h u asempl therefrom and Oe butt for the alleged exemption.My violationof
Section 7031.5 by any applicant for a permit subjects the applicant in a d"I Penaltyof I I Occupancy Type
nm mom Ilan Bw Wished dollars(M).
❑1,u awuer of tie property,ormy employees with wagesss then sole compewdon,
will do the work and theauumum is not intended"offered fm We(Sm.70/1,Business L id Inspections
and Profeadom Coda:The Contractor's Llce" nse Law does not apply m an owner of j P
pmpertywho WLldsorimprows Menem.and who dom+uch work him+elforthmugh hit
awn employees.pmvlded that such improwmenuare not Intended aro@red fomes.if.
however,the building or improwment Is sold widen one yeu of icmpledon,Me ownsr-
builder will haw the burden of proving that a did not Wild or improv for purpose of
sal I.
1,as Monter of the pmperty,am mclWwly mntretting with licensed canuumrs to '
mbuct Me pmjM(Sec.7044,Busu as and Profetaoro Code:)The Contractors Li.
cense law does not apply to w owner of property who buLIN or improws Manson.and,
who contracts for such pmjccm with aconusstar(s)licensed pursuant An the Canmcmra
LiensLw
❑ism empt under Sf. /�f,����'' .B k P—Cyf" b reason,
Owner S Dau /_�
COM ATION DECLARATION
I hereby affirm under penalty of perjury one of the following decluallom:
I haw and will maintain a Certificate of Consent to selbinsum for Waher+Compen.
cation,As provided for by Sermon 37M of Me Labor Code,for the performance of the
work for which this Permit is Issued.
❑I haw and will maintain Workers Compensation Imuran.As requited by Section
3700 of the Lanor Code,for the performance of Me work for which Mis permit is Issued.
My Worker's Compensation Insurance carrier and Policy number see:
Carrier: Policy No.:
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(Missectlan need not he completed if to permit Is foronehundred dollars($10(0
or lose.)
I eartif-v Mat In the rGumence of the work for which this Permit is issued,I shall not
emPloyanyperson crsn ome rvb eclmthewo 'Co pcnuadon
Laws ofc.liroml am ,l
Applicant s '
N come subject
APPL f. e n ate of Labor ion,
. s uldm
become hobject y it Workers Compensation provision,of the Uar Cede,you mon
0z forthwith comply with such provisions or this permit hell W dcemed revoked.
.ZiO CONSTRUCTION LENDING AGENCY '
I hereby affirm that there is a comwctinn lending agency for Me performance of
!Yi'� the work for which this permit Is Issued(Sec.3091,Civ.C.)
QLandces Name
0.z Lender's Address
U Q 1 certify that I haw mad Ma Application and mate to.,the abuw informalun is
LL caner.I agree to comply with all city and county ordinances and mate Iowa relating but
Q U building consty"tion,and hereby maintain mpresenmiwo of this city In enter open the
Wslow-memianed property for impeetian Purposes
(We)agree to taw,indemnify and keep hamlets the City of Cupertino against
,n Iiabiliticsjudgmcnu.cents and expenses which may In any way accrue against aid City
U z in onsequenec Mf 1h LranI. 'of this permits.
A LICANT UNDERSTANDS AND WILL COMPLY W17AL ttt���000N-POINT Issued by: Date T S
is
/Z 8 Re-roofs
Sngn u n HAZARDOUS MATERIALS DISCLOSURE a Type of Roof
Will Me applicant or future building occupant am or handle havardoua material
As defincd by the Cupertino Municipal Code.Chapter 9.13,and tie Heath and Safety
Code,Section 35533(07 All roofs shall be inspected prior to any roofing material being installed.
❑Yes C]No
Will Me applicant or future building occupant me equipment or deviw which If a roof is installed without firs[obtaining an inspection,I agree to remove
emit havamoos Aircontaminans As defined by Mc Bay Arta Air Quality Moagcmcm all new materials for inspection.
D rvittT
C]Yen ❑Nu
I haw mad the haallou+mucriah mquimmene muk,chapsr 6.95 of Me Calif.,
ria Health B Safety Code,SeetioN 35305,35533 and 35534.1 undershoot that if de Wilding
does currontI hew a snArt.Met It la my mapomfbllity m malfy the oceupsot of Me
rto ata which meat ' rw ivua"cora Ccniaate rpm aruy. Signature of Applicant Date
//,1,/ All roof coverings to be Class"B"or better
owns r orix . a
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