05050020 CITY OF CUPERTINOs r 4 "`
BUILDING DIVISION PERMIT CON!rR'ACTnR INFORMATION :.
BUILDING ADDRESS: LNB CONSTRUCTION, INC Pr"""r ND 05050020
1 66S CULBERTSON DR
R'S NAME: PERMIT ISSUE DATE
CHRISTIN LAM 581 BELLEVUE AVE. 09/27/2005
E: SANITARY NO. CONTROL NO.
(415) 585-3884
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
RLOO ELECT PLUMB MECH
3 o p LICENSED CONTRACTOR'S DECLARATION Job Description
I Imreby pmt door 1 am licensed under provision of Chapter 9(commencing p
with Section 7")of Division 3 of the Business and professions Code,and my Iicenm Is
n� infull eClass Eea ADD 1092 'LIVING/444 ! G ��D
� z License Class Uc.R
� Dam Contractor LIVING RM/DINING/MS SUI
M
ARCHITECTS DECLARATION
Q 2 I undersexed my plans shall be used as public seconds
LAIL 1 �d
`yo Licensed Pndcane
uil 201f/L
m OWNER-BUILOER DECLARATION Flu/
.� 0 I hereby resume.(Erse an I am eumpl from the GonwnCo Licenu Law for the
0 0 (allowWhiching res.permit
llD ld,Business and Professions..koCade:repair
m or county
$ which requires a permit toconstruct,alcor.Improve,demolish,fie a signed aunmue
-Z
prior to its issuance,
ensedpduantto the the applicant for smhPermit roicense ave wmmcm
teethe) ing wit pursuant tothe provisions of eve Contractor's an cense law(C ode)ce Sq.Ft. Floor Area
$ (comcing with Section 7000)a(Divi¢ionlo(the Busirmss and Professions Cnde)m z 0000
Nat Mn.teexempt thertfrom and dm basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fora permit wbjecu the applicant in a civil pcnity of APN Number Occupancy Type
net seam Nan Ove hundred dollars($500).
❑h as"ars of the property,army employc"with wages u timm sol)eompewtion,
willeomewark,andthaswamei...limmndedw.ff. Afona)e(S".701/,Buainaa Required Inspections
and Profession,Cade:The Cmuacteri name law cora not apply m e an owner of q p
property who Wilds orimpmveuhemn.and who doessmhwarkhimul(orthrough his
own employees,provided mmsuch improvements are nmimmnded araRered(meek.IL
howewe the building or improvement is sold within am year of completion,the owner,
builder will have Um WNen of proving diel M did not Wild ars improve for Purpose of
sale.).
Rl 1,as owner of then propeny,am exclusively connecting with licensed c0nuaaon to
construct the project(Sec.7044.Business and ProWsiam Cade:)The Canux7nrs U.
acme taw dean not apply m an owner of propeny who Wilda or improves timmen,and,
who contracts for such pmjeots with.contractor(s)licensed pursuant m the Contractors
License Law.
❑lam exempt under a .B k P C'"""mann
130100
4 Dam �W iRKER'S COMP A ION DECLARATION
1 hereby affirm under penalty ofperjury one of the following declwdons:
vend will maintain a CeNrlwm of Consent w self-Wase fea Watror.Compen-
is provided for by Sedan 3700 of the tater Cade,fm the perfmmana of the
r which this permit is issued.
ve and wild maintain WorkeM1 Gmpewtim Insurance,u matched by Section
f the Leter Code,far the performance of the wart fa which this Permit Is tuned.
rkers Compeuetim Inwnna amu and Poliry number tie:
. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this sccsim need Mt W camPlcmd Ifft Farrah Isforave hundm idollan($100)
or less.)
I certify Nat in the performance of the work for which his permit is house,I shall not
employany peracommaymmmr ute core bjearothe Worken'Compew0on
Laws 01C.111. ✓�/p CC
ApPllunt /�n/O � u-
NOnCE PLICA :IL iner $this Canlncam of Exemption,you seated
become subject to the Workers Compemadon provision of Um labor Cod),you mon
�z forthwith comply with such provision or this permit shall Wdccmedrowkcd.
OCONSTRUCTION LENDING AGENCY
F IWeby a(rmn dust there is a comuuninn lending agency for the performers of
rL> the work for which this permit Is Wood(Sec.3097.Civ.C.)
�W Q Lemices Name .
7 z Lender's Addeo
U Q 1 certify that I have mad this application and sum mu the ateve information is
ly F toren.I agree be comply with all city and county ordinances and sum laws elating m
0 building construction,and hereby amhode representatives ofthiamlly to enter upon Um
U.1 aWve-mcntionW property for inspection purposes.
say (We)agree to save,indemnify and keep harmless the City of Cupemem against
in Oabllitiea,judgments.costs and expenses which may in my Way aam)against cid Chy
U Z In conegame of the greening of this pemti.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: da Date
SOURCEDNc
�14,7 O� �
Re-roofs
areGofAphcaSignuUiContrcor
Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupani store orhandle havamaus material
Ocnnd by dim Cupenim Municipal Code.Chapter 9.12,ane dm Hanish and Safety
.Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yen )TN.
Will th)applicant or future,Wilding occupant use equipment or deriaa which
If a roof is installed without first obtaining an inspection,I agree to remove
hamnl.us air contaminants u donned by the Bay Area Air Quality Management all new materials for inspection.
ic17
❑Yes t�ffo
1 have mW the hondnus materials mquiremenu under Chapter 6.95 of the Califor•
7d.
ealth A SafmyCoeo,Section 25305,25533 and 25534.1 undemund that if ilk Wilding
not currently hew a moan.door It u my responsibility m ratify Um occupant of Ne
emcnuw'chmun Wme anceafaceralmamor Ocapanry. Signature of Applicant Date
GLUT 9-D,7-OS All roof coverings to be Class"B"or better C
Owner m authommd agcm Dow