05040135 CITY OF CUPERTINO 77
BUILDING BUILDING DIVISION PERMIT i#CONTRACT R4I�NF,ORMATIO, N,
BUILDING ADDRESS: J H LEWIS GENERAL CONTRACTj:JPE"NGO 5040 135
OWNER'S NAME: PERMIT ISSUE DATE
E
NE: SANITARY 0. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0 0 0 0
+�+Oa LICENSED CONTRACTOR'S DECLARATION
to w1 hereby affirm that I am licensed under previsions of Chapter 9(commencing Job Description
with Section 70)1)of Division 3 of the Business and Professions Code,and my license is
oi m full force and effect. / �s�—
�gz LieenaeClats�_Lie,a (� 310CY�G ADD 738 ' (MS BEDRM/BATH/LAUNDRY)
—'o Datecunu.cwr COVERED DECK/ELECT UPGRADE/WATER SERVICE
A CHIS DECLARATION
1 understand my plans shall No used as public records
D y u ®®® CCC��� n
O. Licensed Professional g �{oe r1�e �®
` 3 OWNER-BUILDER DECLARATION (u� tau�`sVrry/ Bq�a
F I bemby mr.n that I am exempt from the Contractors License low for the
00 following much.(Scction IID 1.5,Business and Professions Cmlc:Any city or county
K m which mquires a permit to connect,after,improve,demolish,or repair any alrucmre
prior to its issuance.also inquires the applicant(orsuch permit to file a signed sutement ��OOd
that he is licensed pursuant In fie provisions of Nila
e Cmmenn's Liccna .(Charter 9 Sq. Ft. Floor Area O ; L Valuation
FFG (commencing with Section 70(10)of Division 3 of the Business and Professions Code)or
i $ that he is esempl Ihe.fmm and the basis for the alleged cmirp i n.Any violation of BUILAqqq IlIsaa�/�..iaasaahhO... $120000
section 7031.5 by my applicant fon permit subjects the applicant m a civil penalty of APN Number CCU ane Type
not mom than fine hundred doth.(ssoB>. P Y YP
❑I,u manta of fu property,m my cmplmyces with wage u dteir sole<ompcnation,
will do use work and the swctum u not intended mmlfered fonak(Sec.7044,Businrsi
and Professions Code:The embracing,Liana law does not appy m
to i owner Of Required Inspections
property who Wildsor improves thereon.and whodues suchwork himself ter drought his
own cmployr provided that such imprommenu am not intended or offered for sak.IL
Incrawyet,the building or improvcmcnt is sold within one yea of completion.Ne owner.
builder will have On,burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the pfopeny,am exclusively contracting with licensed L'mmmctors Ire
coutrucl the pmjcct(Sec.7044,Business and Professions Code:)The Contractors Li
toe raw dors not apply in an manor of propany who builds or improves lemon,and.
who common;for such projects with a eonuaemr(s)licenced pu ognt a the Contracmrs
License U-
0 1 am camp,under Sec. .B&P C for this mason
Owner Dat
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjory one of the following declarations:
1 have and will maintain aCcnificam of Consent to alf-insum for Woric r'sComfcm-
sation.as provided for by Section 37W of the labor Cock,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Wofkcr's Cosepewtion Inmran¢,as required by Section ,
370(1 riffle labor Code,for the performance offt work for which this permit is issued.
My Workers Compemation Ins�unna artier and Policy number art:
Cartier: r�P /^YIC)G7 Pmliry No.:
ERTIFIATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This scetion need nut Ire romfletad if Ik panni,is formnc hundred dolls.(5100)
Or dens.)
I certify Nam in the terfOrnmea of the work for which this permit is isucd,l shall not
employ any person in any manner m as to become subject to the WorkcraCompcnaation
laws of Califmmia.Date
Applicant
NOTICE TO APPLICANT:IL nine,making this Certificate of Eamptimn,you should
become subject m the Worker's Compevauon pmvisiom of the lahar Code,you must
.JO forthwith Comply with such provisions or this fermi,shall h deemed revoked.
Z` CONSTRUCTION LENDING AGENCY
[-�. I hereby affirm that fere is a connection lending agency for the Performance of
!Yi the work for which this permit is issued(Sec.3097,Civ.C.)
![7 Lender's Name
jZ Lcnders Address
V 0 1 cenify that 1 have mad this application and sum the'One above informatiun is
ly Fcorrect.1 agree to comply with all city and county ordinances and sum laws relating to
building construction.and hereby inforia Mirmsenutises ofthis city to enter upon One
V
,r .hove-mentioned property for inspection pmpmsea
&NDD
and ka the City of Cup miso against
F'y li ilities jua may
nyway acvuc against said City
U Z conte mil.
PPLI AD WILL PLY WITH ALL NON-POINT Issued by: Date
U E —zr�� Re-roofsgrature ofAppli onummr Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tM applicant or future building Occupant mom or handle hanNous material
u defismd by the Cupertino Municipal Coo.Chapter 9.11,and the Henftb and Safety
cWe,Scntirim 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant future building If a roof is installed without first obtaining an inspection,I agree to remove
pp g occupant use equipment or devices which g
.u hazardous air contaminants u de0ncd by the Bay Arca Air Quality Management all new materials for inspection.
District?
0Yes JCNo
have mrd fie indmissmmatei ials mquiremenu under Chapter 6.95offcCalifor-
a &Safe' X15.1 and M.lundemundfwifflc building
d curen in Hari my hes po hility b nuufy the oarpom of On
quip nB ie us ma Of in than facc,uffemeofOccupancy. Signature of Applicant Date
mer or authorized agent _ Data All roof coverings to be Class"B"or better
C'