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CITY OF CUPERTINOr�A:4:ePa°:%
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101
NFOW"Te IfO'O N
BUILDING DIVISION PERMIT
,
CUN'TRrtCTQRI
BUILDING ADDRESS
JEAN PARISH
"ah"TNDfl 6060232
6127 SHADYGROV D
OW NER'S NAME:
FERMrr ISSUE DATE
JEAN PARISH
06/28/2006
NE:
SANITARY NO. CONTROL NO,
ARCHr(ECI'/ENGINEER:
BUILDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby arrive that I am Iimnscd under provisions of Chapter 9 (mmmencing
with Section 70f113) of Division 3 ofdw Business and Professions Cam. and my licema Is
In full fo... Meffem
REPAIR OF FIRE DAMAGE TO EXISTING STRUCTURE
License Class Lle.n
Dem Contactor
ELECTRICAL
ARCHITECT'S DECLARATION
I understand my plans &.11 be used u public rerorm
Licensed Pmfcssiom l
OWNER -BUILDER DECLARATION
I hereby elEml that 1 am exempt from the Comrecwn Lkcon Law for the
fallowing reason. (Section 7(D 1.3, Business and Professions Cade: Any city Or county
which requires a permit in ennmucl, eller. improv. demolish, or repair any structure
prior to its issuance, also requlrcs Ne applicant for such permh to file a signed slaloment
Sq. Ft. Floor Area
Valuation 0
Nat he is licensed pursuant w the provisions of Ne Convector's License Law (Chapter 9
(commencing with Section 70D0) of Division 3 of the Buslnaa and Professions Code) or
that he is exempt Therefrom and me basis for dw: alleged esemption. My violation of
Section 7031.5 by arty applicant for a permit subjects the applicant in a civil peaky, of
pp N [�jumber
Occupancy Type
not mare than An hundred milers (5300).
3 7 5 4O 011.00
❑ I,asawnrsofthe pmpeny.ormy wploym with cages asthehsole mmpensetion.
Required Inspections
9 P
willmthe work and the someone, is moin¢nded ora@red fertile (Sm. 7044, Business
and Proslam code: The Conuacwn Ikea. ut Law dam wManor t apply w an owr car
rm
property who buildsorimprow thereon. and whodoessuchworkhimselfortiun ighnu
ownemployas, provided that such improvements arc not intended oroffered for sale. It.
however. the building or improvement Is sold within one year of compledon, the inner -
builder will haw the burden of proving that k did net build or Improv for purpose of
side.).
I, u caner of 0r. pmpeny, am eselusiwiy,oelsasting with Ikensed me rxwa an
mustma Oto projea (Sec. 7044. Business and Professions Cade:) The Caatraaols U.
cense Law does not apply in an owner of property who solids or Wprows thermal. and
who contr cu for rocs pmjecu with a mn0aclm(s) Reared Pursuant to theCantnewr'a
License Law.
❑Tom ase der Sec , B Is P C for Nis reason
Deu
Do er
WORK�'i' CO PEYSAVOR DECLARATION
1 hereby affirm under penHly of perjury ane of the fallowing declarWonc
1 haw and will commam aCemBawaf Consent w self -Insure for Worker's Cont
union, u provided fm by Section 3700 of the Labor Cam, for du performance of the
work for which Nis permit is issued.
I law and will mainum Worker's Camp monition Insurance. as required by Section
3700 of the labor Cade, (w Ne performance of Ne roots for which Ni, permit h Issued.
My Worker's Compensation Insu mance artier and Policy number arc:
Carder. Policy No.:
CERTIFICATE OF FXEMFITON FROM WORKERS'
COMPENSATION INSURANCE
(TMssecia. need eat he compkled Hthe permit is raromnaathmmBan (SILO)
or less.)
1 «nffy that in the rf mos of nk at 0u wafor which thpermit h Weed, l shall not
cmployanyperso any manner Wormirecompensation
Laws afCalifa am
APPlkan, A,
NOTICETO P 'ANT: f,si m in this Certificate of Exemption, you Mould
become subject ue0w Wo les Compensation provisuns of the Labor Code. you must
' foMwith comply with such provifiaus W thin permit shall be decreed rcvaked.
CONSTRUCnON LENDING AGENCY
ing n lendagenry (mNe performance o!
1 herby affirm Upe mere 4 •ed
' me work for which this permit is issued (Sm 7091, Civ. C.)
(Sm 3
Leeden Name
leeden Address
j I aniry, that I hew read this application and stave Nn Nc chew information is
correct. ) agme in comply with all city and county ordinances and stale law mining w
building construction, and hereby authorize ronsionmriva or this city to color upon the
above-mentioned property for lmpeetion pugneus.
(We) agree t0 Hw, indemnify and kap har1111W the Lily of L'upcflinO agaiml
i liabilities. fad{menu. code sed expenses which may In any toy amine against said City
1.comegmecaafthegantingofthispermk
r APPLI NT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date -�Lfvv
SOUR REOULA
-as' USO
fir
-
Re -roofs
Type of Roof
sl `urcol'A ianvCo Dale
HAZARDOUS MATERIALS DISCLOSURE
Wiil OleappllcanLorfuwmbuildingaaupanLnoreorhandleha usmaterial
as defined by the Cupertino Municipal Code, Chapter 9.13, and the Health and Safety
Cam, section 23S32(a)? Na
Ya
All roofs shall be inspected prior to any roofing material being installed.
❑
If a roof is installed without first obtaining an inspection, I agree to remove
Will The applicant car future building occupant uta equipment or halm which
II harandous air catamimmus as defined by the Bay Area Air Ouelily Mansgenlent
all new materials for inspection.
District? .0 ON ❑Yus .7rvu
1 haw real the haxadnus malorials requirements undcrchapurb.93 of theCalifor-
nkHeslN&Safely Cam. Section 2530,15533 am125334. I understand thulfthe bailout
dam col nently haw a loan4 that box y waponsinllity w notify Ne occupant of the
mgelre wnkhm he Ipriorw a,naaracenifkaloorampan,r.
Signature ofApplicant Date
m
All roof coverings to be Class "B" or better
ow rorauNa v ag nt