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CITY OF CUPERTINOx•xi''
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BUILDING DIVISION PERMIT
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'BOWLBY
BUILDING ADDRESS:
JIM & SHU MEI CH
PERMIT No.06070039
19705 STEVENS CREEK BLVD
OWNER'S NAME:
PERMIT LSSUEDATE
1. JIM BOWLBY & SHU MEI CH
E:
SANITARY NO. CONTROL N0.
ARCHREC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 thereby affirm that 1 am licCesed under proviso. of Clients, 9 (.-OO.-ftP
with Section 70M) of Division 3 of the Business and Prolmio s Code, and my liens' is
in full force and ertsct
REVISION -ELECTRICAL PANEL CHANGE
Liccnxclass Lin"
Date
ORIG PERMIT #06060109 -NO NEW PERMIT
DECLARATION
TSDECL
As
I understand my plans shall W used as public records
mail use
Licensed Prulessional
OWNER -BUILDER DECLARATION
1 hereby aRrm Nm 1 em exempt from than Contractors License Law for the
following mason. (Section 703 L5, Business and PrOfesdmu Cmle: Any city Of county
which Rquirrs a Permit in ennsweL alter, lmpo war, demolish. or repair any structure
! prior to its issuance. also requirnat the applicant(ora"h permit to file a signed statement
Sq. Ft. Floor Area
Valuation $0
i thathcpursuant islicensedpursuanoNeprovisionsoftheConnecmrsLicenselawfaajuer9
(commencing with Section]000) of Div Won 3 of the Business and Professore Cade)w
l e basis for the alleged empuOn. Any violation of
that k u exempt sMm mfruand Nx
APN Number
Occupancy Type
P y YP
Sections 7031.5 by any applicant for a permit subjeeu de applicant in a civil penalty of
not mom than Bre hundred dollars ($500).
31620083.00
❑ 1,. owner of tW poriew'."my employ'. with wam as their sok compensadon,
Re uired Ins
will do me work. and be structure a not intended"Offered terrab(Sm. TON, Business
and Professions Code: The Contractors Liana law it .tout apply to an owner of
q P ns
property who builds or improv. metnun, and who dao such work hirreselforthrough his
own employees, provided that such improwemenu are not intended oroRered for salt. If.
howev.. the Wilding or improvement is to widuh one year of cmopinion, the Owner.
builder will nave de When Of proving that he did Out Wild or Improve far purpose of
e ,
ashi,.
1, as Owner of property, am.clus contracting with t.
/
3/
am Code:) The Contracbh Li -
e�tfect the a (Sec. 7044, of a� :) The
nee re, who bus
law deo 001 apply b is own. of property who WiWa"improv. Centra. red,
out
.no
wbo contracu ("such WoJ^eu wimarnntraz )licensed pursuant in the Contractors
License Law
❑lam emp rylp-Sec .Bk PC far this
Dwner Data
V
WORKER'S COMPEN TION DECLARATION
1 hereby.Bute under Penalty of perjury one of the following declarations:
-
haveaadwill maintain aCertificate ofConsent toself-insure [of Workers Compton.
-
sauon, as proviMd for by Scotian 37M of the lab" Code. for Ce pertines. of the
work for which this Permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as "aired by Sccuon
3700.f on UWi,Codc.for tW perfrom. Ofmr work I. which this .it is issued.
'
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ThaxNon need not W coinplcmd if the Permit Is torose hundred dollars ($;M)
or less.)
1 ccrdfy that in me performance of the work for which this Permit is issued, I shall not
employ any person in my manORr� tO.Weoop�ubject b the Workers Compensation
Laws of Califrnia.�g T 15 ��
Applicant ff fir", , ✓
NOTICE TO APPLICANT: If. after making this Cerdricate of Exemption, yen should
beemme subject in me workers Compctuatirn previsions of the LaWr Cede, you must
' forthwith comply with such provisions or Ca permit shall W dcamed ¢voted.
i CONSr,
I hor by a a conNLENDINGngagenY
agency fir th'perfurmance of
thatmem aanot(Sce,
0lending
' which
the wash far which Nis permit a issued (Sec 3097, Civ. C.)
Landers Nan'
LCMers Address
'
j 1 certify mat 1 have read this application and sum that th' above information is
' comem. I agree to'amply with all city and county ordinances and state laws misting to
building construction, and hemby autbon7e mpmacnuines of this city to enter upon the
alWvc-menuoncd property, for inspection purposes.
I
(We) agree to save, indemnify reit keep harmless the City Of Cupertino against
i liabilisuitur judgments, costs and exyocswhich may in any way accrue against to City
in coreequrnce of the g lin{ of Na it.
' APPLJQAt{7' UNDE ANDS ILL COMPLY WITH ALL NON -POINT
-
Issued by: Date
SOIIR[E RE 0
��!`
Re -roofs
Snt^ ort OTApplicautco^wcbr Date
HAZABDOU9 MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future Wilding "cupmt start"handlc haraNOus material
as dcrined by the Cupertino Municipal Code, Chapter 9.13, aM the Halm and Safety
Cade, Section 25532(a)?
❑ y. U�"r
All roofs shall be inspected prior to any roofing material being installed.
ww thea Beast or (own building aecn
Ire a pant tax equipment Or devices which
If a roof is installed without first obtainingan inspection, I agree to remove
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ha/ardnua air contaminants u de0ncd by the Bay Arca Air Quality Management
all new materials for inspection.
bR O
❑Y. vu
1 have mal the haardom materials requirements under Charter 6.95 of the Califo>
me Hut" Safety Code, Sectiones 25505,25533 and 35534. I msdersuM than ifmr Wilding
u"s n rRn0y h0we tenant. my remumihility b notify de occupmt of the
R g=hKlfm^�Wmet rr Iasuatr:ofaCetifcam—rryoeaapm(f�L
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Signature of Applicant Date
L. V
All roof coverings to be Class "B" or better
o errrarmrrbadasen, Date