05050021 CITY OF CUPERTINO '� -+ n
BUILDING DIVISION PERMIT CONTRACTORNFOR,MATION:�`
BUILDING ADDRESS: LNB CONSTRUCTION, INC PERMIT No.05050021
1665 CULBERTS D
0R'S NAME: PERMIT ISSUE DATE
CHRISTINA LAM 581 BELLEVUE AVE 09/27/2005
E:
SANITARY NO. CONTROL NO.
(415) 585-3884
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGPL
ELECT UMB MECH
0
uOp
LICENSED CONTRACTORS DECLARATION Job Description
n 1 hereby affirm quiprovisions of 1 am licensed under provisioof Chapter 9(commencing
�iO, with Secum.7rR())of Diviaiue 3afthe Bush=and Professions Code.and my license is
mmOfarecmdeffect. DEMO (E) HOUSE (EXCEP,T.,FOUNDAT.ION)
jlI? License Class Lia.# 7
sp DateContractor
'J' ARCHITECTS DECLARATION
rev S ).'t'1Z
I understand my plans shall he used as public records
JiU
e u. Lkcnaud Proreional
c3
xOWNER-BUILDER DECLARATION M!1V ✓8 2005
Y 1 hereby alfir.that 1 am exempt rmm the Convectors License law for the
e O O following reason.(Section 703 1.5,Business and Prole ions Cole:Any city or county
i m which requires a permit to construct.able,improve,demolish,or repair any structure !i -vb, it a q,GMA $5000
yzi prior to its issumce.also requires the applicant for such permit to file a signed statement ♦ r %i ytei ,__
i< that he is licensed pursuant to the provisions of[he Contractor's License Law(Chapter 9 Sq. Ft. Floor Area [Ls u[rel ss>>"SJ✓]Valuation
YFO (commencing with Section 7raXb of Division 3 or the Business and Professions Code)or
y 5 that he is exempt therefrom and the Buis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of r U U Occupancy Type
not more than firs hundred dollars(55003.
I,uownuofthepropeny,mmyemploy wiNwguutheusolecompensation,
will do Newark.end lee he Cmuituar'. t. oronered fid Out apply
1061, wne,of
and Professions Code:The Improves
uencon,License Law dans qor apply to an Owner or Required Inspections
property who builds or improvesch improvements
and who does such work himselfor edNmagh his
owneer.the u,p Wilding
or i quit such ret is
sold
wit in not intendedmoffcrcd for sale. r-
however.the building or improvement is sold within one year of c mala for thepose of
builder will have qM burden of proving Nat he did not build or improve for purpose of
sale.).
1.as owner of the property,am exclusively contracting with licensed eanuacuirs m
construct the Matter(See.70,14,Business and Professions Code:)The Convacsar's Li.
cense law doe not apply to an owner of property who Wilds or improve Merton,and.
who contraca ho,
o,such pmjem with a conlnctoKs)licensed pursuant b the Contractors
License Law.
❑lam eve. qts Sec. .B&P C for this maxed
,Un Dam
WORKER'S C5MPENSATION DECLARATION
I hereby afErn under penalty of perjury,arc of the following declarations:
vc and will maintain a Certificate of Consent o self-insu.fm Workers Compcn-
n..Provided for by Section 3700 of Ne labor Code,for Ne perfoonnnee 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 later Code,for the performance of the work fm which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This auction uead not hO completed if the permit is Enr one hundred dollars(SIIX)
or less.)
1 certify that in the performance of the work for which this permit is imucd.I shall not
employ any person in my manner so t mo Cbjecuo the Workeri Compenwtion
Uws of Califam' — � >
Applicant tfQ /zHGE
NOTICE TO LICA :If,a0cr m ung this Ccnificale of Exemption,you should
become subject m the Workers Compensation provisions of N.labor Code,you most
.JZ forthwi In comply with such provisions of this Permit shall lx deemed mvokcd.
Z CONSTRUCTION LENDING AGENCY
(-. I hcrchy aRrin that them is a commax,lnn lending agency l'm the performance of
aL Ne work for which Nu permit is issued(See.3097.Civ.CA
V] Lmd.ra Nam.
G Lender's Address
U C) I certify that I have read this application and sure that the above information is
U. Pcanes.1 agree to comply with all city and county ordinances and titan laws relating to
U building construction,and hereby amhoriaerepresentatives of this city to enter upon the
r Cil above-mentioned property for inspection purposes.
6. (We)agree to save,indemnify and keep harmless the City of Cupertino against
Fw TA liabilities,judgments.cam and expense which may in any way accrue against saidCity
U in consequence of the granting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 60 Date ez
SOURCE REGa�s�
e 0 n 9-��-QS Re-roofs
Sign urco— fA�ppllcan�UPunniixfData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store Or handle hazardous material
as defined by Ne Cupenino Municipal Code.Chapter 9.12.and the Health and Safety
,gdllkc,Scenes �No
2553200725532007Ye All roofs shall be inspected prior to any roofing material being installed.
�
Will the applicant or future building Occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air contaminants as dermad by the Bay Area Air Quality Management all new materials for inspection.
❑Yes XNu
I have read on,hvardnus ingen.lsrequirements under Chapter 6.95 of the Calif.,
ai.Health&Safcty Codc,Sued.25505.25533 and 25534.IundcrsuM NuifNe Wilding
doe not curmmly have•tenant that it is my n apmaibilky to miry the mcupmt of the
requirements whomug hc.ctpnormrsse a.facerarmatcofp�cupancy. Signature of Applicant Date
1��1� 1 �/Ia7-0� All roof coverings to be Class"B"or better
bw cr ser authorncd agcm a¢