08050166 CITY OF CUPERTINO � " *meq -
eU1LDING DIVISION PERMIT COi r MICTOR INFORMAT, 01
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BUILDING ADDRESS: PERMrr NO.
7828 CREEKLINE DR GRIDLEY COMPANY 08050166
NER'S NAME: FERNM ISSUE DATE
` GILBERT NANCY AND CHEW ROLLIN 122 ORCHARD CITY DR 05/21/2008
PHONE: SANITARY NO. CONTROL NO.
(408) 374-0900
ARCHnYC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECf PLUMB MECH
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sept
LICENSED CONTRACTOR'S DECLARATION lob Description
mr'E 1 heranions by arm tint 1 am Imedme
'umunder Pmvisimasou ofof CMPlor 9(commencing p
4withSeemat7000)ofDiHuan3oftheBeer.andProteud.Cade.aul keds RMD MSTR&HALLBTHS (150SQ) &OPNG CHG IN LVNG&DNERM&
^�� in run tomo arta arm to
'q D maac class CLomgr.mr RMDL KTCHN(17 8 SQ)
e RCHI7ECTS DECLARATION
? U I understand my plans shall he used as public recumu
ea
5G Licensed Professional
y
OWNER-BUILDER.D the Com7ION
COS Mmhy o(S m Nn I am exempt from the Comm�ah License c Law far me
Sp O follwhich on rtuaa(Saito co I3,Buslter. and rm de oli Code:Any dry or rouure
$� which requires a permit m construed allot.impmw,demolish,m repair any structure ' '
_x> prior m its issuance.aim requires the applicant for such Permit to file a signed statement
'EYG thuM is licensed p..nL m the pmvi4tu of lM Conuawr's Lw<me Lsw(Chap¢r9 'Sq:Ft.Floor Area Valuation
sat— (commencing with section 7008)of Division 3 of the Business and Profruinru Cone)or $70000
e 5$i Nat he k exempt tMrerrom and the hub for tM alleged exemption Any violation of
Section 7031.5 by my applicant fora permit subjects the apple.,m a civil penalty of prr,s77 Number Occupancy
not mom man fmw hundred dollars(s30o). 36217065 A V' P Y Type
I.0 owmr of ties property,or mY emPloyces with wages.they anle comperuadon,
anddo thewmk,.d the he Coreramtmsemensor new dos an,apply to an nen of
.d Professions,who code 7M Contmcmrs License law does rot apply m an n ugh of Required Inspections
property who builds a impovaach i mn,and who aasouchwm intended oroffformrovgh his
man e .meuiprovideding or
pral suchimPmsemenuare not arofmooned Formithe owner.
builder
builder,me building or Impmwm.n is mid within ane year of mm oro:fou the owner-
btilder wise Mw doe burden of province that M did rot build a improv tar purpose of
suck.).
❑1.u awmr of the property,am naelusiwly commuting with liecasW mmaamae to
mutmct me project(Sec.7Wd,Business and profeulons Cance:)The Cmtracmra Li.
cloud taw does not appy m an owner of property,who builds or impmvu demon,and
who contracts for such prejecu with a contractor(s)licensed pursuant an the Contractors
hearse law.
p l am accept under sen ,B A P C for this reason
Four Dau
WORKERS COMPENSATION DECLARATION
1 hereby&from mender penalty or perjury one of tM following declarations:
❑IMwaM will mumwna Cmtificau of Coesentmself-inwmforWarkers Camper
.it.,ar p m,kind for by section 37110 of me,labor Conte.For me perhome a or me
work for which Nb pmmi,is intend
❑I Mw and will maintain WorkcYs Compensation u required by Section
37M of the Labor Code,for the peRormance or the work for which rob Fermi,or issucd.
My Workemrs.C,00mp ossa ion r.�ce carrier and Polity nu ��
Cartier. �S - 64 -4CJ&'IWPoliry N.,
CERTIFICATE OF DLEMMON FROM WORKERS
COMPENSATION INSURANCE
(robsectian cd..t Mcmmplead if me Imuch is forane hundred don.(SIM)
ro les>)
1 cm lily mal in me perrmmaae of the work for which this permit u issued.l Wll not ..
employ anypermn in my mmmrsu as m become,subject to the Workers'Compewhm -
Lawn of California Dau
Applicant
NOTICE TO APPLICANT:IL aMr making this Certificate of Exemption,you Mould
became subject m the Worker!OmnpcMhbon prom knots of sun Lahne Code yen most
.,O fothwimh--III with such Fm limned or this permit Mall M deemed remla d.
?(A CONMUCIION LENDING AGENCY
[r1 hereby affirm mat ft.b a comucti
trm lending ap.7 for the pnrformacx of
FL > the wart for which this panni,k issued(Sec.3097,Ci,C.)
1 Q lenders Name
D z Lenders Address
U C) I cerdlY that I Mw road oris application and sues then me&bow inlmmatim is
LL F c0mocL 1 aped in comply with all city and county ordlunces and sum laws mbdng to
0U building mMtuction,and hereby.thoom mpreaematiwa of mis city to color upon me \
ahow-ms.judg dpmpertym for iupecim.c.purposes.
F a. (We)agree m sew,indemnify and kmp hamlets the City of Cupertino agai=
h Iiabmucquudgmenh.cwuand g upemesmit. may in-1 way acme.,.,I send Gty
U z A cansegucnee of me granting of this permit.
APPLICANT UND ST NDS D WILL COMPLY WITH AL NO -POINT Issued by: Date
RCE RE N Q t ��
J Z Re-roofs
S' a;a(Appl HAZARDOUmuConurac S
am
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
W10 the applkammfuture Wildingettupantmsrn .and huardaumaterial
u a�Sec io and Cupertino Municipal Code,.chapter 9.IZ,.d the Halm.d Safety
.s0yes z(&)+ All roofs shall be inspected prior to any roofing material being❑res �a g installed.
Will me,applicant or future building occupant see equipment If a roof is installed without first obtainingan inspection,I agree to remove
ned
PP t p q Fuerst w dMana which
emit haaNnu air conumirunu u defincM Try tM Bay Arta Air Quality Management all new materials for inspection.
District? N P
❑res Jam""
I hast real tM haardnumaloriair requirements under Chapmr6.95ofmd Califon.
fib HulN&Safety Cadc.Smiom 25505,25577 and i55W.l undvst.d Naifdw
Wilmot
does no,currently ha •lonseL that it h my responsibility m notify me upset of sun
t,wmeh Wcant pafarmme. f,Corur, Xgov, Signature of Applicant Date
ow r ratma zeaapnt
'onto All roof coverings to be Class']¢ or better
L