06050241 CITY OFCUPERTINO •� `
BUILDING DIVISION PERMIT �N�TR. .GTpI � I
4..S.wemr�s."s+� §4•ueR Mme&"
BUILDING ADDRESS: SHAKONE & DEE ZEHAVI PERMIT ND.06050241
21827 TERRACE DR
OWNER'S NAME: FERMTT(SUE DATE
SHA ONE & DEE ZEHAVI 07/12/2006
E: SANITARY NO. CONTROL NO,
ARCHITEC IENOINEER: BUILDING PERMIT INTO
BLDO ELECT PLUMB MECH
i Q LICENSED CONTRACTORS DECLARATION lob Description
I hertby.M.that i am IIcovN under prouar
viu of CMptor 9(commcming P
fwith Section 7")of Division 3atda:Businessland Notiosvions Code,and my license is
„ Wfall faroemdeffe". ADD 8191 -4TH BEDROOM/BATHRM/ENLARGE (E) BEDRMS
?13Z License Class; LW.N
it Deal Contractor & LIVING RM/ENLARGE & REMODEL KITCHEN
ARCHITECTS DECLARATION
f 1 understand my plans shall W used as public records
yyU
9Q� Licensed Profcssianal
OWNER-BUILDER DECLARATION
I hemhy a1Brm that I em exempt from the Convectors license Law for the
C a O fallowing mason.(Section 7071.5.Business and Professions Cade:Any city or county
ca
.9 which m pdres a pump to cnnsuuct,alar.Improv,demolish.or repair my s ac,um
Zg Women.prior to iWomen.also requires the applicant forsuch permit to file a signal statement Valuation
- that he is licensed purmanitothe provisions ofthe ContractoriUcanseLaw(chapter 9 Sq.Ft.Floor Area
e�� (commencing with Section 70DO)Of Division 3 Of the Business and ProRsei^ns CMc)or $254557
.- that hat b amara%therefrom and me hub far the alleged assumption. try
violation of
Section 7071.5 by am applicant fora permit subjects the applicant W a civil penalty of APN Number Occupancy Type
not mart am five hundred dollars(SLID).
❑L"Owner of the Property.a my employees with wg"u their sale compensation,
will dotheworkindthe ammum brudimendedoraffeedformle(Me.71144,BadmvR Required actions
and Professian Crude:The Contractors License Law ease,not apply W an Owner of 9 P
property who build,m i mpro ma mhmasm.and windlass s oath wart himself or through his
awn employees.provided met such Improvement,arc n t(mlanded moRered(orale.If,
however,the building or Improvement Is mid within am year of completion,the current.
builder will have the burden of proving that he did not Wild or Improve far purpose of
❑I,u Owner of the property,am emlusively contracting with Iicnmd commctors W
construct the project(Sec.7044.Business and Profession Cade:)The Contractors I.I.
cense law dma not apply in..Owner of property who Wilda ar ireprowa Werom,cod.
who contracts for such projects with a conuamrp)licensed pursuant W the COnumWrs
License Law.
or.. ,B&PCtor Warman
u aAw Dau 31&101
WORKERS COMPENSATION DECLARATION
I hemby of lm order penalty of perjury oro Of the following declzmdum:
❑I ham and will mainWn a CaruBau of Consent W self-iuum fm WorkeesCompc^-
Rulm,u provided for by Secdon 77000f the lahar Cade.fm the performum ruf the
work for which this permit is issued.
❑I haw and will maintain Worker,C^mpmmtlm IRNMQ,as Rgalmd by Section
3700 of the labor Cade,for clad performana^f the work for which this Permit is Issued. '
My Workers Campewdm Inmrarce cannot and Policy month"tae:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(IhisseeOm^cod mtbeeampkmd if the permit Is forma hundmddOOars(SIM)
or lea)
1 certify met in the performance of On,work for which this permit Is Wood.I mall am
employ any pavan in my meaner an as W become subject to me WorkersCompensation
IJWa of C. sea.Data
Applies I ��
NOTICE AP CA :If,after making this ordnance of Exemption,you should
became subject W that warkcr's Compensation provisions of the labor Code,you muss
w, foMwith m comply with such provisions this Permit W hall deemed rammed.
O
z CONSTRUCTION LENDING AGENCY
E.r I hemhy affirm that them is.co mnetinn lending agency for the performance of
�i
due work for which this Permit is issued(Sec.3097.Civ.C.)
W�Q Lenders Name
7 Lenders Address
U I certify that I haw mad this Application am Stain that the show Information Is
W F correct.I agree to comply with all city and county ordinances and Rude law m Wing to
O U building construction,and hembyauthorim representatives of this city to enur upon the
Lf7 ahavc-memiu^ed property for inspection purpose.
C (We)agree to save,indemnify and keep harmless the City of Cupertino against
,y fA liabdides,judgmceb.cmta and eaperves which may In anywaymcrue again,mid City
U`L in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
Sqy CE REGU ONS.
�r Re-roofs
Signam.of ApplicanuCm
onmWr —� D°W Re-rof Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applinnd or fu,um Wilding areupam,Wro m lundle havAau mamriel
an denued by the Cupertino Municipal Code.Chapter 9.11,and the Hcalm and Safety
,Sectim15s31(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ?. Na
Will the applicant or future Wilding oaVpant use equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
molt husrdnu air co iammaru u dented by use Bay Ama Air Quality Management all new materials for inspection.
DisuicV LL,�
Oyu ❑Nu
1 haw mad the huardoumueNals mquimr^e us under Chap er6.95ofine Califon
niaHmlth&Safety Code.Seetimu25305,25533 and 25534.I wWcmmd dualftiW Wilding
don not currently bow a tenan4 mu It It my msponamilicy W wfify the ca upan,cot the
=tswhle^h-� be metp'riortoWu,ma^f a Certificate ofOccapnmy. Signature of Applicant Date
�"'�" 6�'^'� ,•0-10 All roof coverings to be Class"B"or better
Ownefmmthodmd,tend /' DaW