03040016 (2) CITY OF CUPERTINO E ` ` ` '
BCO
UILDING DIVISION PERNIIT , NTRACTOR INE'O9,M-4' I"
3M iu;-5'�'rP »�•n�•:�,ei>4 t�
BUILDING ADDRESS: PERMITNO.
10172 FIRWOOD DR LENTZ CONSTRUCTION INC, J 03040016
OW ER'S NAME: PERMITISSUEDATE
HOLBORN HARRY 5087 MAITLAND DR 04/02/2003
.I
(408) 264-0555 SANITARY NO. CONTROL NO.
ARCHMICrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION
Ou❑ 1 busby arum Nat 1 am licensed undo P113,01310113 of Chapas 9(commencing Job Description
zzk� with Seeuon70W)of Dlvision3ofdm Bus nessentl Profculnw Cads,wdmyliecnacis
n?w in full fora en e0. �-
5n z_ uanwClus 'ShRi� INSTALL KITCHEN SKYLIGHT (3 ' '
LCc
lj- Dace ARCHITECI'SD R T 'O ('N''
Ica tM my plans shall W used'u public rtrords ' ���®
DWU
;9LLS Licensed Proteuianai APR 0 8 2003
�0 OWNER-BUILDER DECLARATION 9991 hereby affirm that I em exempt from ted Cont.aors License taw for the
`G o following moon.(Section 7031.5,Business and Pwfesumu Code:Any city or county
$ which requires a permit to construct,star,improve,demolish,or repair my structure
Fid print to its issuance.slam requires led applicant for such permit to rile a signctisuamcm
that be is licensed pursuant to the ptavislom of the Conlnetori Lianw Law(Chapter 9 Sq.Ft. Floor Area a ua Ion
m
$ (cameming with Section 7000)of Division 3 of the Business and Professions Ced $e)or 1875
.. Net be Is esnmpt tbemfman sed Ne hub far Ne alleged exemption.Any violation of
Schon 7031.5 by airy applicant far a permit subjects the applicant II a civil penalty of Occupancy Type
notmart then esu hundred della.($500} + S� W O O
1.u owner of the pwputy,m my employcea with wages u Nab role cmnpwu0on,
will do Ne work.and Ne s uclurt Is not imended or offered for sale(Sac.7004,Business
sed Professions Codc:The Contractor..License law dos rat apply to an away of 101 - FOUND PP4JI Inspections
pmPenywha builds or improves human,and who doessuch workhimmlfmNmugh his 102 - PIERS
ownemployces,Mannino ino that such improvements ate not intended ntoRened forums If,
however,the Wilding or improvement is sold within one year ofeampletion.the owner. 103 - UFER
builder will haw Ne burden of proving Nu be did am build ar improve far purpose of
sale.). 104 - REBAR
❑I,as Iwnae of the progeny,am caclumety eont.ming with licensed contractors to 105 - ANCHOR BOLTS
consumer the project(Sec.7044.Business and Professions Cade:)The Contoweri Lb 1O6 - SEWER & WATER
cense taw does not apply to an mum of property who Wilds or impww thenen.sed.
who contracts for such pmjeea with a contranor(s)licensed pursuant to Ne Contnmor's 202 - UNDERFLOOR PLUMBING
License Law..
❑lamas ptwdmSec. B PC far this arson 203 - UNDERFLOOR MECHANICAL
a 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DEC67kATION 205 - UNDERFLOOR INSULATION
I hereby affirm under penalty of perjury ane of Ne fallowing declarations: 301 - ROUGH PLUMBING
bih.wmd will humin a certificate of Consent to sel6imu¢for Waskefs Compen. 302 - TUB Tic OR SHOWER
ration,u provided for by Section 3700 of Ne IaWr Code,for the performance of the
work for which this Permit isiuued. 303 - ROUGH MECHANICAL
❑1 have and will maintain Worker's Compensation insurance,as required by Section 304 - ROUGH ELECTRICAL
3700 aftW labor Code.farted perfarmwa of Ne wort far which his permit is issued. 3O5 - FRAME
boor is CompensationInsurance canter and Policy number an:
Cam ->h rc F •,,] PoncyNo.: 1400-;) 7 -02'- 306 - HOLDOWNS
CERTIFICATE OFEKEMP`nON FROM WORKERS' 3O7 - INSULATION
COMPENSATION INSURANCE
India stomas need not W catamount ifthe Permit is fmane bundeaddollars(SIM) 308 - SHEETROCK '
ter
Ica.) 309 - EXTERIOR LATH
1 unify slut in the perfamom.of ted work far which his permit I,Wood.l maul no 310 - INTERIOR LATH
employ any Person in any manmr an as to become subject 10 Ne Workers'Compm3mjOn
taws of C 311 - SCRATCH COAT
uifarau.Data
Applicant - - 313 - ROOF NAIL
NOTICE TO APPLICANT:If,after making this Comfica eat Exemption,you should
became subject to Ne Worker's Compensation previsions of one tab.Code.you must 501 - FINAL ELECTRICAL ENERGY
Zz N
forthwien.ptywithwar
ehponochmthbpanah,halxdcemvok
demand 502 - FINAL PLUMBING ENERGY
`N-,
CONSTRU(71'IroONLENDINGAGENCY 503 - FINAL MECHANICAL ENERGY
(r ibemhy eRnm Natlbertimanstrocuan lending agency forted Performance of
Qi > the wmkfor which this permit isiuucd(Sec.3W7,CmC.) 504 - FINAL BUILDING ENERGY
W p Leader Address
505 - FINAL ELECTRICAL
Lender's Name
U0 1 certify Nat 1 have read Nis application and sus that 0m above infonnuiun is 506 - GAS TEST
correct.I agree to comply with cal city no county Infamous and sera laws relating to
0 U building conwuction,and hembyauNodnmirmsemilhasofthis city acnarupon Me 5 7 - FINAL PLUMBING
D.l
above-mentioned property for impaction purposes. O - FI L MEC ICAL
(We)agree to cave,indur ufy and keep harmless Ne City of Cupertino against
fn'q Iiabilitica,judgments,eosta ndexpenscs which maymanywaywcrw agalnstuid City O9 - FI
U Z In consequence of the granting of Nb permit.
^� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIN'r Issued by: 5 INC' Dale
SO RCE REGULATIONS. _ QR
Re-roofs
"Pus tercof AM icanuContrutor Datc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will ted applicant Or form Wilding occupant nam arhandhnm
le vaamaterial
u defined by the Cupenino Municipal Code.Chapter 9.13,and the Health and Safety
Cade,Section 35533(;)7
❑Yea Otho All roofs shall he inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment or devices which
If a roof is installed without first obtaining P g an inspection,I agree to remove
am D4it
uhnrardnus air caniamimou u defined by the Bay Am Air Quality Management all new materials for inspection.
❑Yes p9.
I have mW the havannus materials requirements under Chapter 6.95 of the Califor.
ni.Health&SafetyCodc.Sections 25505.25533 am175534.1 unticrsund that if the Wilding
does not currently havc a tenant.that it is my mapamibillty re may Ila:eccupant of Ne
mimmenu V -which most heIn prise usuancc lfa Chir, IPecm Signature of Applicant Date
�, o. ��� a
D.naIm mthan,<d agent DOW All roof coverings to be Class "B"or better