07100195 CTTY OF CUPERTINO �������� �����,������ ;
BUILDING DIV1S10N PERNIIT �. ,
, PERMIT NO.
BUILDING ADDRESS: TBD — T�) BE DETERMINED 0 710 019 5 .
21751 OLIVE AVE
pEgb11T LSSUE DAT6
owr�RS xaME: ' 11 / 21 / 2 0 0 7
EDWARD XIAO SANITARYNO. CONIROLNO.
PHONE:
BUILDING PERMiT 1NF0
:CHTIECI'lENGiNEER: � EO PLU ME�CH
y p � LICENSED CON7'RACfOR'S DECLARATION JOb DeSCi1pL10I1
� v � ���b �� �� � am �iccnscd undcr provisiona of CAaptcr 9(commcncing s FDW RM ADD I T I ON ( 4 5 5) & ENTRY PORC H( 4 0)& RMDL
� Z� wiU� Sccuon 7Q00) of Division 3 0l' ihc Businev and Pro(cssions Code. and my liccnsc is
��y infuli forcean de f fect. �� � MSTR BT H R M� N O R E— R O O F I N C L U D E D
� v� z Licensc Class _.--- Conuac�or
j F , p Da1c
ARCHI7'EC1'S DECLARATION
,� �� 1 undcruanJ my plans shall bc uscd as public records
m
�
y Q y Liccnsed Pcufcssionel
OWNER-BUILDER DECLARATION
�< � 1 hcrcby afGrm ihat 1 am excmpt trum ihc Conuactors Liccnx Law Cor thc
i p O following rcason. (Scction 7031.5, Busincss and Profcssiuns Cak: Any ci�y or county
y,°, Pi which rcqui[es a pertnit to consUUCC. a�lcr. imPmvc• d�mnlish, ar repuir any suucmre V3Ill1t10►1
prior to i�s issuancc, also �cquires �hc applicant far such permit to filc a signed sta�cmcnt g Ft. Floor Area �, 0 O O O
' z< �hat he is IicenscJ pursuant to thc provisions o[ ihc Conuacar's Irccnse Law (Chaptcr 9 q•
� t �(commcnring wi�h Secdon 7000) of Division 3 of �hc Busincss and Profcuions C�dc) or
y�� �hat Ae is exempt theietrom and the basis [or d�e allcgcd exempUon. Any violation ot Occupancy Type
SecGon 7031.5 by s�y apPGcan� fw a P�cm�� s�bjecu the applicant to a civi] penalty of 3 5 718 0� 7�(� Number
not more than five hundred dollars (5500)•
� 1. u owner o[ tl�e proPertY• or my employcea with wages u the'v sole compe�waUon,
will do Uie work. and Ihe sttuc�me is not intended or offeted farsale (Sec. 7044 sus�nes+ Required Inspections
and Ro[essiom Code: 71�e Contncwr's License Law does not apply w an w+ner of
property who d�ilds or improves the�con, and who does such work himsel[or tlwugh his
ow� empbyces, provided ihat such improvemmts are not iniended or otkred for sale. If,
hawever. �be boilding or impmveme�t is sold within one yar oC completion. the owaer-
builder will have the barde� o[ proving that he did no� build or improve far pu�pose o(
sak.).
, u awnec of the property. un uclusively conuuting wiW ticensed rnnvactors W
eo uvct the projett (Sec. 7044. Business and Pro[essions Cade:) The Contnctur's Li-
cenu [aw does not apply w an owoar of property who builds or improves theroon, and ,
who convac�t Cor such projecb with a conlrutor(s) licensed pursusnt to 1he Convsctor's
License Law. , B dc P C for �his reason
❑ I am exompt un�Sec.
� �� �
oW� �.�
. �g ON DECLARATION
1 hemby aflicm under penalty of perjury one o[ the follawinB dec�arations:
r] 1 hs+e and will mainuin a Cutificate o[ Consent to ulf-insurc for Workcr's Compen-
ion, u provided for by Secuon 3700 oC the Labor Code, for �he pedarma� o� �
rt (or which Nis pnrtnit is issued.
❑ I havc and will maintain Workers Compensauon ]nsurance, as rcquired by Scction
3700 of the Labor Codc, Cor thc performance of 1he work for which �his permit is issued.
My Workers Compensauon Inwcance carria* aod Po���Y number a�e:
Cartier. Policy No.:
CERTIFiCA'fE OF EXEMPTION FROM WORKERS'
COMPENSA710N INSURANCE
(IT�is section necd not bc comple�cJ if the pe[mit is for anc hundred dollars (S 100) ,
or less.)
I ceni(y �ha� in �hc performancc of Ihc work for which �his permll is issucd, l shall not
employ any person in any manncr so bccomo wbject w o ' Compcnsation
Laws oC Cali(omia Datc
Applicant = D rni
N077CE TO APP NT: If, aMt making �hu eruficatc of E�ccmpuon, you shoulJ
become subject w thc Worlcer's Compensation provisions of U�c Labor Codc, you muu
�,� forthwith camply with such provisions or this permil shall bc dccmcd revokcd.
Z � CONSTRUCTION LENDING AGENCY
[.r ►�-� I hcrchy a[firm �hat thcre is a consuuction Icnding agency Car the perfortnanx of '
pf, � ihe work [or which this permit is iuued (Scc. 3097, Civ. CJ
W Q Lendcr's N�mc
] � Lcnder's Address
V � I certify �ha� I have read Iltis application and sute U�al �hc a6ove infwmatiun ia
w � comct. 1 agrce to comply with �II citY and county ortlinances and aute Iaws relaung to
� U buildin6 consuuction, and hereby authori�e rcprcsentativcs of ihis ciry w entcr upon the
ahovc-mcntioned p�operty for inspection purposes
�" a (We) agra to save, indcmnify and kecp humleu ihe Ci�y o[ Cupertino ageinst
�� liabilities, judgmcnts, cos�s and expenscs which may in any wr+y accruc againsl said Ciry � /
V z in consequencc oC �e granung o[ this permii. DSi6 `�� �-�/ ��
� APPLICANT UNDERS'fANDS AND WILL COMPLY WITH ALL ON-PO1M Issued ty :
SOURCE ULAT10 •
� 2/ �' Re-roof s - �"
signai can � �°� T of Roof
H ALS DISCLOSURE YPe
Wip �he appliant or futwc building oaupant uorc or handlc ha•racdous ma�crisl
u defincd by the Cupenino Municipsl Code. Chaptcr 9.12. and �he HealU� and SaCcty
c� .Section25532(a)? � All rool's shall be inspected pcior to any roofing material being installed.
� Y� o �
�11 thc a�licant or future building occupant usc cquipmrnl or dcvices which
If a roo r is installed without first obtaining an inspection, agree to remove
cmit harardaua air contaminanls at efcfincd by Uie Bay Area Air Quality Managcmcnt all new materials for inspeciion.
��svi��� �J �
�ya �,
1 havc roa�i �he ha�acdrnu mamrials requiremcnts undcr Chapicr 6.95 of ihc GliCar-
nia Hcalih & Safcty Cadc. Sccti 505.25533 and 25534.1 undcts�vid ihat if Ux building
docs nol curtcnlly havc a mn Ihat it is my '6iliry W�rotiCy Ux occupant of �hc Date
reyui�cmcn�s �chmust meipriorwiss o[a fica�cotoccup �r• SignatureofApplicant
� All roof coverings to be Class "B" or better
Owner or a agcni Da