07060022 CITE'OF CUPERTINO ra�,�
BUILDING DIVISION PERMIT '
PERMIT NO.
BUILD06 16)RESS:
GO� 5 JOLLYMAN LN-LOT 3 SHASHI LLC 07060022
PERMIT ISSUE DATE
OWNER'S NAME:
SHASHI LLC 06/21/2007
SANITARY NO. CONTROL NO.
JNE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
i p Q LICENSED CONTRACTOR'S DECLARATION Job Description
UI hereby affirm that I am licensed under provisions of Chapter 9(commencing
z with Section 7000)of Division 3 of the Business and Professions Code,and my license is REV I S I OT'' TRUSS CALC S, ORIGINAL PERMIT
H in full force and effect.
rr�z License Class Lic.# #0 7 010 O C 3-N0 NEW PERMIT
p Date Contractor
E v� ARCHITECTS DECLARATION
i aJ
< I understand my plans shall be used as public records
)qU
U. Licensed Professional
.cc OWNER-BUILDER DECLARATION
,vi_J
1 hereby affirm that 1 am exempt from the Contractors License Law for the
co following reason.(Section 7031.5,Business and Professions Code:Any city or county
<09 which requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance.also requires the applicant for such permit to file a signed statement Valuation
z r Ft.Floor Area
a that he is licensed pursuant to the provisions
of Contractor's License Law(Chapter 9 L]• 0
XH (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of35922 0 6(► �Number Occupancy Type
not more than five hundred dollars(5500)
❑1,as owner of the property.or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion.the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractors)licensed pursuant to the contractor's
License Law.
❑[am exempt)under S c _,B&P C for this n
Owner Dam 152Z
LWORK OMPENSAIION DECLARATION
ercby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insum for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(chis section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any marine so 0 bject to the Workcrs'Compensation
Laws of California D
Applicant
NOTICE TO A LICANT:If,of aking this Certificate of Exemption,you should
become subjec the Worker's Compensation provisions of the Labor Codc,you must
,J forthwith comply with such provisions or this permit shall be deemed revoked.
z "" CONSTRUCTION LENDING AGENCY
E~—c V) I hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
0 z Lender's Address
U Q 1 certify that I have read this application and state that the above information is
LU E~ correct.1 agree to comply with all city and county ordinances and state laws relating to
U building consuuction,and hereby authorize representatives of this city to enter upon the
>4 (We)above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
H (� liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
►4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE GULA S.
d Re-roofs
Sigure of Applicant/Con Date Type of R not
HAZ US MATERIALS DISCLOSURE yP
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cole,Section 25532(a)? All roofs ;hall be inspected prior to any roofing material being installed.
C3 Yes Ct
Will a roof i;installed without first obtaining an inspection,I agree to remove
ill the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as dcfi y the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes u
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which m t be nor to issuance ora certificate of Occupancy. Signature of Applicant Date
b All roof coverings to be Class"B"or better
O e�., uthorized agcn to