04030008 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �a`C�ONTRACTOR&INFORMATION
BUILDING ADDRESS: PERMIT NO134030008
O 4 0 3 0 0 0 8
220
R'S NAME: PERMIT ISSUE DATE
JIM LENTFER
NE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uoo LICENSED CONTRACTOR'S DECLARATION JobDescri [ion
C 1 hereby affirm that 1 am licensed under provisions of Chapmr 9(commencing P
b with seem.70 )of Diviaion3of Ne Budrras Profeulom Code.andmylicerucis �I ry�
=y inml1fine, cleff«t. ADD 133 SQ. FT. /REMOEL/SEIS
�i License Class Lie.g M E{p�l
Lev
i o- Da. Contractor
',j c"� ARCHITECTS DECLARATION
1 understand my plans shall be used as public record,to
y) rstl001
t' Licensed Portman...I
Off L
5 OWNER-BUILDER DECLARATION
. I 1 hereby offmn that 1 am exempt from the Contractor's License Law for the
—0 0 following¢tion.(Section 703 1.3,Business and Professions Cade:Any city or county
s'�.e—v dui which vision.a permit I.eonuruct,altar,impohm demolish,or repair any toward.
HZapoor to its issuawe.also requires the applicant for such Permit to file a signed statement
that he is licensed pursuant to Me provisions of the Command's Uumc Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)a Division 3 of the Business and Professions Code)or
w. that be u exempt Oerzlrom and the bel fm the alleged ertmption.Any violation of
Semon 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3 ®I`]� Pl O O Occupancy
not mom Nan Bas hundred doll.(5300). P y Type
❑Lo owner ofdd propesy,mmYemployees withwagesasde'v sole 0,14,8 Business will dothework,and Oe sh Comismes Limedoro@rttlrorsath(Sm.in ad,,Business
and Professions Codc:The Improves
desor,License law dors tot apply to an awws of Required Inspections
own em whobuildo orimpotes Neiman,endensodacnotint work orciffror for We Els
ownemployees,Provided that men impmsementhinnot eariderapled dforowru-
Wilder r.Ne building or improvement is sold within one year of completion,on,owe of
builder will have Me bmmAra of proving that be did not build or improve for purpose of
sail'.).
ip 1,as owner of the property.am exclusively unuati ng with licensed contractors to
comtmct the project(Sec.7064,Business and Professions Code:)The Conus tad's U
cense law dos not apply to an owner of property who builds or improves thereon.and
who contracts for such projects with a conuaetor(s)licensed pursuant to the Communes
License Law.
❑Iameaempunder5e ,B&PCfm Nisrtason
.r Date
RKER'S COI IPENSATI N DECLARATION
1/ hereby affirm under pcnslty of perjury ore of the follNp(dociaattions:
I hale and will maintain a Certificate of Consent N self-insum for Workss Compcn.
cation,as provided for by Section 3700 of the Labor Code.for the re furmance of Ne
work for which this permit is issued.
O 1 hays and will maintain Worker',Compensation I....as required by Section
3700 of de Vbm Code,for the Performance of the work for which this permit is tissued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Oblwmom wed not be completed If the permit is forow hundred dollars($100)
or less.)
I unify that in the performance of Ne work for which this permit l bound,I shall not
employ any person in any mannerso as to become subjmi to the Workers'Compensation
laws of Califomia.Data
Applicant
NOTICE TO APPLICANT:If.alter making this Ccnifrcate of Exemption.you should
become subject to N.Workers Compensation provisions of the lahm Code,you most
.,O foMwith comply with such powisimus or Mia permit spall be deemed o voltam.
'Z..'�5 CONSTRUCTION LENDING AGENCY
N
[—m k for which thi Nnth.rt iso issued
len ding agency for the perfiumancepf
a the wont for which Nit permit is issued(Sec.3047,Cl,CJ
G Q Lender's Nam.
,Z)Z dander's Add.
U 0 1 unify that 1 have read this application and sum Nn Use above information is
V. f" conect.I.&.a I.comply with all city and county oWin..,and state lwa Hating to
DU building construction,and hereby euthonrc upresentatim of this city to cncr upon the
D.1 abeve-memooed property for inspection pummes.
gym
(we)ague h save,indemnify and keep harmless ft City of Cupertino.geinst (
h liabilities.judgmen.,casts andespente,which may in my way wemc against said City
U z in consegrcntt of Ne gr.nring of this .it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:S4Date
SOURCE ULA S.
"-r// Re-roofs
of r HAZARolcm. S MATERIALS DISCLOS� ata Type of Roof
Will the applicant car furore Wilding uecupanr aorz rehandle hvardons nodmial
declined by Ne Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Sc.timn 255320)7 All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,I
Will one applicant or forum building occupant use equipment or devices which g agree to remove P
it ha
Diiardous air contaminants u defined by Me Bay Area Air Quality Management all new materials for inspection.
❑Yes �INo
I have reed Ne hvaNmms maerialsrcyuirtmcnu unmkr Cheperh.95 of the Glifor-
w)ic.ltha SafetyCode.Smc=255 .25533ud25534.1undcnu if Ne Wilding
does net no him•.nand,that it l my responsibility to notify the occupant of Ne
rtyuirt swhic a be mer priorwissuance ofa Ccrfic 76"'
f cuparty.
G Signature of Applicant Date
nernr a ',ed assns Date All roof coverings to be Class "B"or better