08010049 CITY OF CUPERTINO
BUILDING DIVISION PERNHT aCC1 IT12e�i.CTGTR�X I''l?TtMATIfyN.�s-
ia3¢ pzv :,ss� r •.F°� Sa .�:.C,
BUILDING ADDRESS: PERMrr NO.
20619 SHELLY DR TBD — TO BE DETERMINED 08010049
HER'S NAME: PERMITISSIIEDATE
HO JEAN C AND GILBERT D 02/26/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDGO EO PLO MINCHO
O o LICENSED CONTRACTOR'S DECLARATION
is 1 Wmby affirm mat 1 am liceund under provisions of Chapmr 9(commencing Job Description
wire Section 70(M))ofDiWaian3ofine Buaincsa anpd Pro(cuia..C.dde,arWmylicenceis ADD 490 SQ(2 BDRM, IBTH) &RPLC 1 WNDW W/SLDNG DOOR
nen u AdIrme.mcieffm p3D�0 d
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g_ Dam vwComamer rsA?S 9uyto/9✓k-Pc.+
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ARCHITECTS DECLARATION
I understand my plans shall W used as public records
:ty0
yo Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
COO following mown.(Section 7031.5,Business and Prefecture Cade:Any city or county
$fi which requires a permit m cone nce.ser.improve.demolish,m repair any stnmtum
Zi prior to its issuance.also requires the applicant for such permit to file a signed statement
that he is licensed Pursuant m me provisions of ren Conuacwr's Lane law(Chapter 9 Sq.Ft.Floor Area [. Valuation
rLFB (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $80000
3- mm he is attempt therefrom and Bre bash for the alleged eumpdon.Any Wolmlon of
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty ofNumber Occupancy Type
not more man five hundred dollen(SSW). 3 5 9110 21
❑1,u owner of the proper$,m my mvploym wire vngu u thekuk mmpenatim,
will em Newark,and thestructum is Iwtimended conflicted forsa c(See.7044.Busiws
and Professions Code:The Cantrumrs License Law does ml apply to an owner of Required Inspections
property who build,orimprovv theremand who doessuch work Mm ndfm0trough his
awnempleycus,provided mat such improvements art notintended aroffesnd for We.If, "
however,the Wilding or improvement is sold within onc year ofcomplehon,the owner- - --
builder will have the burden of proving that W did not build or improve for purpose of
ask.).
❑1,as owner,of be PrepefY,am exclusively contracting with IiceruW contrumn to
conaem<t the project(Sec.7(119,Business and Profusions Cada:)The Commencer'.U.
cease law does not apply to M owxr of property who Wilds or improve thereon,and,
who contrute for such projects with a eontramor(s)Iiutued pumunt to the Contractor',
l.kensu Law.
❑I not exempt under Sec B k P C farthi,mason
nu WDate
PENWORKER COMSATION DECLARATION
I hereby affirm under penalty of perjury oro of the fallowing declaredons:
1 have and will mainhin a Cenifiateo(Consent k al(-Imam far WorkehCompen-
ution,at provided for by Section 37M of the Labor Code,for the performance of the
woke for which this Permit is issued.
❑i have and will maintain Workers Compensation Insurance,u required by Section
3700 of the Labor Code.for the performance of the wutk for which this permit is iumd. '
My Workers Compensation Insurance aria and Policy number am:
Carrier, Policy No.: _
CERTIFICATE OF EKEMMON FROM WORKERS'
COMPENSATION INSURANCE
(Nis section need not W cemplemd if IW permit is farone hundred dollars($1011)
ear kat)
1 ccouCy that in the performance of the work for which this permit h issued,I shall not
employanypersoninanyma rso��bomo subject to the Workers'Compensation
laws of Ctlifottnn'a Dam /�
Applicant /E /s NA
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labm Code,you must
.JO forthwith comply with such Provisions m this Permit W deemed revoked.
z '-t CONSTRUCTION LENDING AGENCY
[-a t,4 I Wmhy affirm that them is a construction lending agency for the performance of
ai me work for which this Permit is iumd(Sec.3097,Civ.C.)
WM Q Lenders Nurse
7 z fender's Address
V I certify mat I haw mad this application and sum that the shove infomrstian is
Iy F coram 1 agree to comply with all city and county ordinances end stale laws mleting in
.0 U
Wilding construction,and hereby aumt,riu representatives of this city m enter upon the
WUabow-mentioned property for lmpcaWn purp=L
(We)agree to ave,indemnify and keep harmlea the City of Cupertino against
w.t rA iiabilifiea.judgments,casts and expemes which may in any way unme against mid City
(„)'z A APPLICANT
of the gramUNDERSTANDS
SA AND
,v / / o-
"" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date ,C/—.
SOURCE 59ULATfONS.
Re-roofs
Sigentumof Applicam/Conraztor �—
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future Wilding occupanbmre or handle haaudous materia
u dcOmd by the Columnist,Municipal Code,Chapter 9.13,tad dm Health and Safety
.Section 25532(,)?❑Yon pp aa��AANo All roofs shall be inspected prior to any roofing material being installed.
Will the applicantr
tor Wilding occupant use equipment of devices which If a roof is installed without first obtaining an inspection,.I agree to remove
emit ham tire,air comanninants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yee k1'fio
I have mad the Weardm/u7�materials requirements underChapter 6.95 of the Califor.
nia Health&Safety Cade.Secdons 25505,25533 ami 25534.1 understand than if the Wilding
dam net currently haw a tenant.that It Is my responsibility to no the occupant or the
Mquimmen0 h must W mel pri m issumme of a CcniOcem
/J�� 1/°"�°�`y��-- Signature of Applicant Date
Owner or e�eN 'sa`d g
All roof coverings to be Class"B"or better
}on4 � Date'