08020051 777
ill'S
Y OF CUPERTINO . r . .mgw�AF=; r '- -
BUILDING DIVISION PERMIT kCON'LRACT�QR INF,ORMA'L'IO�' '
'YVDfµE :STATES DR TBD — TO BE DETERMINED 08020051
NAME: PERMIT ISSUE DATE
ARY SHEN 05/01/2008
E: SANITARY NO. CONTROL NO.
IIECT/ENGINEER: BUILDING PERMIT INFO
Bo 0 0 0
trop LICENSED CONTRACTOR'S DECLARATION Job Description
w 1 hamby affiom Nat 1 w licensed under Provision.of Chapter 9(mmmcssems
w1NSeuio.TO[)O)T' DitI 3arNe Budnrsa ane Protesdom Code.ana myliccrssu DEMO HOUSE
in full fore.and errant.
Licema Clan Lin.L
t-p Dam ConuazNr
Q 7W ARCHIECI•S DECLARATION
WU 1 understand my plans mail be used as public records
s o Licensed Professional
^ 3 OWNER-BUILDER DECLARATION
i i E I kmby anion that I am eacmpt from Ne Canines License Law for the
C O OC Philmont,reason.(Salion?11313,Busixss and Profesduas Cade:My city Or county
which requires a permit in construct.a)ter.improve.demolish,or wpm any Wuctum
prior to its issuance.also requima the applicant for such peomit m file.signed simunt
<
that he is licensed puestunt to to providoas of the Conbmmfs ue.roe Law(Chapter 9 Sq.Ft. Floor Area Valuation
x� (commencing with Section 7")of Division 3 of Ne ess Businand Promsemns Cache)., $1000
Y R$_ Nat M is exempt demeans and the basis for me alleged exemption.Any violation of
nota than byairydreddontfarapewitmbjcctsNeapplicantmativilperulryor Number Occas ane Type
not am Nm firm nastama dollen(ss0a). 36924004 . P Y YP
I,a ower of de pmpcny,or my employees with wages n their sole compensation.
will oro the work,and the ser num It mm mended or offered for sale(See.TDH,Bandanna
and Profeadoes Cade:The Cemeacme,License Law does not apply in an owner of Required Inspections
propeny who builds or improves demand,and who does such work himself or duvugh his
Own employees,provided that such improvements am not ineMed maffamd forsale.If.
have ear.Ne building or bnprovemant u said within arc yam of cmoplesiw.the awn e, -
builder will hast the bundm of proving Nat W did Out build or improve for purpose of
vie.).
L u awrc a she popcny,the exclusively wnuaeting with Homed mnaactors us
wan the pmjett(Sea 7044,Business and PmRssime Cole:)The Cenvacnr's U. .
crone Law does not apply to an owner of peopeny who builds or improves thereon.and
who cenaa.t for such projects wild a eomoo mr(s)licensed pressure to the Contractor's
Linen aW.
❑lama ser See ,B&PCfor this mason
Dame
WORKER'S COMPENSATIONDECLARATION.
1 be by from order penalty of perjury aro or the rallowinL declarations
1 have and will maimam acudfinm olcomert to self-inure rurworker'scompen-
noun,as provided for by Section 37M of the labor Code,for the peAowmm of Nc
Werk far which this remelt is ivued.
❑1 have and will maintain Work s Compcasation insurance,as required by section
37(l tie tabor Codc,far the peRarmmm ofine work for which axes pe.it h issued '
My Woridn S Compnusadon Inaramx carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu Minn need nothe completed if the pewit is(orate hundred!dollen(LIB.)
m Inv)
I unify amt in the perfoomance of the work in,which Nispewit u issued,l shall not - -
empmymyName irmymmarer so us m became sub's dsaW Imrs pertauon ,.
Laws
of CdifomiN
•^
Laws rot
NOTICE UG ,ittlil making this ccrtifieson of Eacnption,you should
became subjeu in she Woher's Compensation provision or Ne Labor Chun,you muss
.J O forthwith comply with such provisions or this permit mw
peit null W decrA mkcd.
z v-' CONSrRUCI30N LENDING AGENCY
(-+ I hereby anirm that Vert se a conaauction lendinga fm the E
tie wank far which Nu .)nary per(awvxm of
IL7 rs Lender's Name pemtit u usuA(Sec.3(ISy,Civ.C.)
Dz Lender's Address
()0 1 certify that I have send this appliaaon and me than the"hove information u
5 corrin 1 gree m comply with all city and county oran
dincesand man laws rebating to
0 building construction,mtl hereby authoria reprmsentuves of Nis City In enter upon the
[t7 aMv.-mcnudgmd propertyset for inspection pugwes
G (We)agree to save,indemnify and keep harmless the City of Cupmino against
r/1 liabilities,Judgments,cost anda.,.which may in anyway accrue"gaunt said City
V z A consequence of the jranunL-(this D WIL-
�' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC1F,acr:ULAT10Ns. p
l o °/—°o Re-roofs
fAppinesrt✓Conwcmr . Dae
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicam or future building oavp r tnone or bundle ha>allous¢aerial
defined by Ne Cupenbm Municipal Code.chapter 9.11.and the Health and Safety
O
. yer 155]1(x)? 1$i N. All roofs shall be inspected prior to any roofing material being installed.
Yes
If a roof is installed without first obtainingan inspection,I agree to remove
W II N.applicant or fume building by me Bt use equipment or devices which P g
it int? nn oir cantminmt u defined by Ne Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yn �No
1 have real the ha>ardonmaeri is mquircmcntunder Chapter 6.95 of On,CahifoP
nu Health&SafmyCade Seetimu MM.25533 and 155N.l understand that ifNc baildng
den not currently have a mart.out it u my mspomibil ty m reality use o¢wmt of the
¢qui ts ich mustynnet pd.,n in...of.Ceral cam of Occu
i�^— p Signature,of Applicant Date
a � or- o/—°
owner er atrmwxed"gent Dow - All roof coverings to be Class'A!'or better