03050110 CITY OF CUPERTINO �Brs: M'NAF,
BUILDING DIVISION PERMT cO \IVRAVTOWIT� +' �' r 4to M,a�
,
BUILDING ADDRESS: LENTZ CONSTRUCTION INC, J PERMIT NO.03050110
OWNER'S NAME: 5087 MAITLAND DR P � /22/2003
E: (408) 264-0555 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
O
100 LICENSED CONTRACTOR'S DECLARATION JobDescri tion
I hereby affirm provision 1 am licensed under provon of charmer 9(commencing p
MN
ll SectiToreroon] a(Division Sof the Beat saidProfeuiom Code.and my license is
v in futt
p�z Dad cl - Contractor sS. ♦L INSTALL 3 SKYLIGHTS/6 E E®
3 ARCHITEC'SD ATION
I uMcrsmdmyplansshallWumdapublicmemds DEC 0 4 2D03
LI
eon Licensed Professional
son OWNER-BUILDER DECLARATION
7 1 hereby Affirm that I am exempt from die Conlncloh License Law far the WILDING
2y Q o following mamm.(Section 70313.Business and Profession Code:Any city or county
d e which regolm a penal,to Construct.a]=.Improve•demolish.m repair my nructu,
u y prior to its issuance.arm mquims the applicant for such permit In Ole a signed statement
-veto
that he is licensed pursuant W the provisions of riseContiaptori Uncese Law(Chapter 9 Sq.Ft.Floor Area $Y��lOn'
$ (cammendng with Sued.7000)of Division 3 of me Busumas and Professions Could)or
Y
that he Is eanmpt Neefwm and the bash fm ma alleged exemption.Any violation of
Section 7031.5 by arryappliomfar It permit objects Ne appitum In a civil penalty.( 3AM ISOM18500 Occupancy Type
Dal mom Nen five hundred dollars(M),
❑1.u owner of the pmKny.m my mployces wlN mgu a LWr sok compemdm,
will do Newon.and the suumm b noinsemdW ora@red for Wm(Sm.70th,Business 101 — FOUND2k'jjtPA Inspections
and Profession,Cade:The Commences License Lav dams met apply to an owner of 10 2 - PIERS
property who milds orimve NM through whodoessuch work himselfar ough his
own employees.provided thin such Improvements me not Intended as@red formate.if. 103 — UFER
however,the building or Improvement Is mid Main ane Sear of impletion,we owner-
builder will have the burden of proving that he did Cot Wild or improve for purpose of 104 - REBAR
sem)' 105 - ANCHOR BOLTS
❑1,u owner of the prapeny am reclunvely contracting with licensed contractors to
Construct the project(Sec.7044.Bucmsa and Professions Code)The Chavaetoes Li. 106 — SEWER & WATER
cense Law data not apply to an owner of property who Nrilds or Improve daemon,and 202 — UNDERFLOOR PLUMBING
who centmcts for such pm)ecw with a conuactor(s)licensed pursuant to the Consumes
License Law. 203 - UNDERFLOOR MECHANICAL
❑iamexemptunde Sec. ,BkPCfateismuon 204 - UNDERFLOOR FRAME
ow""" Dac 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
1 hereby aRum under pevity of perjury,ane of the following declaration 301 - ROUGH PLUMBING
❑I have and will maintains CWOn¢of Consent to self-Insum for Workces Compere- 302 — TUB & OR SHOWER
smon,u pmvrdad far by Sweden 3700 of the tabor Code,rte the performance of the 303 - ROUGH MECHANICAL
won far which Nis permit is issued. 304 - ROUGH ELECTRICAL
C]1 have and will maintain Workers Compensation remittance.u required by Section
37x0 of the later Cade.for the pcmmance of the wan for which this permit is Issued. 305 — FRAME
MyWoncea Compensation Insurance Cartier and Policy num ram: 306 - HOLDOWNS
u Slnfz-Fr.nn Pones
.: oaKERs'/'R—S �
CERTIFICATEOF EXEMPTION 307 - INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
Club section need ant be completed it permit is far we hundred dolae(SIM) 309 — EXTERIOR LATH
or leu.)
I certify that in Ne performance of the won far which this pemil'u issued.I shall no 310 - INTERIOR LATH
employ any permn in any manner an as to become subject to the woneri Campemation 311 - SCRATCH COAT
Iowa or California.Dale
Applicant 313 - ROOF NAIL
NOTICE TO APPLICANM If.after making this Ccnincnc of Exemption,you shouW 501 - FINAL ELECTRICAL ENERGY -
beame subject on we Woner'a Compensation previsions of we Labor Code,you must
.JZ forthwith Comply with men interviews,orthis permit shall Wtrammel make. 502 - FINAL PLUMBING ENERGY
Z O CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
(.4 hereby affirm the them baconstruction lending agency far the wrfomaaeof 504 - FINAL BUILDING ENERGY
rL > thewarkfar which this permit I.issued(Sm.3097,Cn.Cd 505 - FINAL ELECTRICAL
Ii)Q Iandcee Namc
] Z LendetsAddress 506 - GAS TEST
Uo Icemtythat Ihave mad Lids application adsaw tat the above information is 507 - FINAL PLUMBING
ly F mrren.T agree to comply with all city and county ordr amen and sato laws wilting to
OU buildingcenstruction.andherebymthorimrepresentativeofMe&citytoenteruponthe — FINAL MECH CAL
above-mationcel property Tor inspection Purposes.
(We)agree to save.indemnify and keep Mannish Ne City o(Cupcnina mom,
y nabllidesjudgmentacosts and expenses which may to anywayaccom agamslsaid Clly NG
t)Z in consequence of the granting of this pcmaiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: C WORKSDate
SOU CE REGULATIONS.
S-w7J o Re-roofs —(��;7 <
ifignalure of AppliunVContector Dam
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant er peace Wilding occupant more or handle havardou material
as defined by Uae Cupertino Municipal Code.Claims 9.12,and the Hearth and Safety
Code,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yms &]No
Will the applicant or-future Wilding occupant use equipment or dcvtas which If a roof is installed without firs[obtaining an inspection,I agree to remove
rl haaardnua sir contaminants u dcnnctr by the Bay Area Air Quality Management all new materials for inspection.
District? ��I
❑Yes i`GfNu
IIIew mad die husurs amecrials requirements underChapear6.95 of the Califon
niaHurth&SafctyCodc,SwUm25505,25533mW25534.lundce NatifNe Wilding
does cwt currently haw a mom.Nat it b my responsibility to notify the mempanl of the
requirements which mumf a Certicec of Occupancy. Signature of Applicant Date
to melpriorseissusnce oSJo03
o erorauNan,<d.eent Dam All roof coverings to be Class"B"or better