05110155 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: KELLY GOREN DEVELOPMENT CCR'PMuNO05110155
21190 CANYON OAK WA
OWNER'S NAME: PElff4rr ISSUE DATE
.10,:KELLY GOREN DEVELOPMENT CO P. 21190 CANYON OAK WAY 02/17/2006
SANITARY NO. CONTROL NO.
ARCHITECTIENGIKEER: BUILDING PERMIT INFO
BLDG ELECT PLUM MECH
9,
00 LICENSED CONTRACTOR'S DECLARATION = n
d M I hereby of irst that I am licamand under provision of Chapter 9(commencing Job Description
with,Section 70110)of Division 3.f she Business andl Prolleadma Code,and toy license is
wfullf...ad eIfrm SFDWL-1 STORY (40031 -LIVING. )
Ll 4 License Class�Lic.P
Date Contractor GARAGE--7041
ARCH TECTS DECLARATION
I understand my plans shell W used as public records
Licensed Phuressi.m.] OWNER,5UIl.DER DECLARATION
i�x I hereby affirm that 10 ettemp,from Me Contractor's License Law for the
m
0 following moves.(Section 7031.5.Business;and Professions Code:Any city or county
which wiluirm.pernait I. .1w,.borrow.dermulials,or repair any mature
prior w its issuance.also requires the Applicant for Such Permit to rile 4 signed statement 6dji861614
Oat the I.licensed pursuant in Me provisions or On Cormcmas U..Law(Chapter 9 Sq.Ft.Floor Area Val
(commencing with Section 7000)of Division 3 of Me Business and Prawssions Cade)or
that We is exempt thcmf=and Me,basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant a a civil penalty of �8T�er
not mom than Five hundred dollars(SSOO). 34 A N . 00 Occupancy Type
0 1,m owner of Ne property,a my employees with wages as their sole compensation,
will dc On w.*.,.d the subactune Is=handed oroffered Rusak(See 7044.11whress 'Required Inspections
and Pmfossions .Law no Oumnswes Llano does not apply to an moor of
property who builds whodues such work Manx i(orthrough his
own employees.provided that attach Improvements are nothrutualed croffered forWe.If.
however,Me building or improwment is sold within one year otcompladon.the owned
builder will have Me traders of proving OR he did not Wild or Improve for purpose of
sal..).
21�.owner of Me property,am exclusively contracting with licensed conwiscur;to
construct Me project(Sec.7044.Business and Prohnsions Code:)The Cownscure,U. FINALED
censeLaw does not apply to in owner or properl Nil"or Reproves thercon,and ---
who contacts for such protests With a con act r(s)licensed pursuant to Men Contractor's
Licess,Law.
El[a marnT c. B&P C I.this resseen OCT 0.ci 2006
Ownu Ikm 241-7 JOG
W KI S MPENS ON ECLARATION I
KE
OMP
I hereby all under Penalty of turn of taw following Owitations:
PT: 7
0 ilowandwillowbraln.Cenificate fComntiowif-insumforWorkeesCom�n- WILDING
station.or provided for by Section 3700 of the Labor Code,for the gwrformarress of the
work for which air Permit is issued.
0 1 haw and will maintain Wmkees Compensation Insurance,as required by section
3700 of the Labor Code,for we performance of the work for which this permit is Issued.
My Worker's Compensation Insurance carrier and Policy number sue:
Cartier. Policy No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tas well.bond net he complcum Ifthe,pernalt is Insane hundred dollars(SIM)
or less.)
I certify that I.to.Puparanine ;fft ork fich NiPermit Is issued,I shall not
c .man la-w Mer-'i*47
�!loyanyrtcrachws of CalifornioW iftWorlocrtfCompermillon
Applicant
NOTICE TO APP ANT I r nualn, I Exemption,you should
woub en au
Labor code.You Most
become subject to the 'CV, iw.1
,JOima.ids comply with a parwitumn,or N' permit hall W seemed mvolwd.
(7 2�1-
z . "STRUCTION LENDING AGENCY
listraby.ffirmcre Is•construction lending agency for the Performance of
Ci On work for which thahm4it I.issued(Sec.3M,Civ.C.)
Uj Lender's Name
z Lender's Address
CJ Q I emity Oat I haw mad this application and saw Oat she throw information a
ly correct,I alince to empty with all city and county ordinances and saw I,"relating a
building construction,and hereby authorim miumennusim of this city to enter upon the
above-mentioned property for inspection purpose,.
(We)agree to UK.indemnify and keep harmless ft City or Cupertino against
ow '
cn labilidesjudgments,costr ads which May in any way accrac against mid City
'1 0 it.
& ng 0 In
U in CANT
secruof a Me
ao
'N
APPLICANTTJWN I AN D W L COMPLY WITH ALL NON-POINT Issued by: 62� Date c,C--
IC
P7
S.URC JL -2-11-7 Re-roofs
Signature orA i D.*
— 0—'
IVARIDS ATERIALS DISCLOSURE Type of Roof
WIIIu rob
u m Wilding orcurcauslone whandle Ismundonsmateral
as defined wswi
Zp" a alCode.Chspwr9.12.tad the U.Ithanis gouty
Code,Secfic�n 25532(n)? All roofs shall be inspected prior to any roofing material being installed.
Over No
Will the applicant or future b5ilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
III hal.andours air cmuserinants fired by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes Nu
a, madachmar on Merl I de oal terti,95oftheCalifor.
c Code sl�can .1"u= ',=dftif
n4licsIM&S'ely I r u 5.25533 1��.I an Me Wilding
f Ac
Jura 0 new by .. n.nh Is so sponsibility ternary inteocculam.rds,
or
mulul m sem Out f.ccrupchw.f up Signature of Applicant Date
,
Owner 'att . . .7 i
lifted iOn, I All roof coverings to be Class"B"or better
r r