00060155 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PIRMI r NO.
OWNERS NA410191 LEBANON DR APPLICATION. f AI:
PHONE: MAXINE ERLUND SANIIARYNf. Lo a.N .
0O7O ARCIIIIECIIIeNGINIJiIi: BUILDING PERMITINT)
w_ BLDG F 1' PLUMB MECH
Q 1_I C "I -1 f_I
LICENSED CO91'RACIOR'S DEChARAIION Job Description
o z y o I nerenr amm,n,n,1 am Ecen,ce amler nnwi,dodnx mclmpfero a,ldn�nelldfny P
with Senior a and of Division J o[the Bminecc and Professions'Cale,and my lion¢
a Y < Liccnr ll fares ellen.
c z a Ddo Clas Lie.M
r..<
r i,G Dam Committal TEMP POWER
Aos sofI r u sa D13CLAItATION
L_°n O; 1 undcrsmnd my plans shall h uvJ az puM1lic mmN.
to
,'n c o O Licensed!Professional
yy z
OWNER-BUILDER DECLARATION
a7 w 1 hereby.Hina that 1 an eacmpt h'om file Comou,ni a License Law for the
following reason.section 7031.3.Business and Professions Code:Any city or county
F c wKab requires a jmnait it),nstrufa,alaa,it... denfolf,th,ormlao,an, m,am
eit
to 3C5= pnm t r I: q the Pt'I u t h pe a 11 .6n J t Inmem
he,1 I dp ,turn,powisions of theComoscoev Liecow La iChaprre) Sq. Ft. Floor Area Valuation
reincarnate,with Section 7000)of Div... o 30,he Bto n and 11refiroi v Code)
or that he is exemp,thercfmm and he basis for the alleged exemption Any violation
Of Secant 9031-9 by any applicant)n a ncnnit eobjects the nppfia nl ,,a civil pcmlry
of not mom than five hundred dollars S500). APN Number Occupancy T l
'L as owner.bile property,army coaluycns whh wage m their sola uwgcnsminn.
will do the work,and the strecmre is not intended or offend for sale(See.7(W. 3421401.0
Blidness and Pod,,tionx Codc:The Contruetor's License law down nn,apply ,,an Bred Inspections
owner of Parisi Who builds or improves,hereon.and who does such work Matter
or through his awn enpfoyees,provided,hat such improvemenR are not intended or
offered for.ale.u:however,the building aimWoveaa ix sold wilnio ooe year of 103 — UFER
completion,the owner-builder will have the burden of proving that he did no,(mild or
dnpnwo forpapr,cofxale} 304 — ROUGH ELECTRICAL_
01,etc owner ohne pro,eny,am eeulnsiwdy contracting won licensed contractor,to
construct the PaNcf(Sec.70,14.Business and Prnfexxiona Code)The Convenor's
License law does not apply m on owner of property who build,a improves the...
and who convncm for each Pn,,v with a unWcmr(a)licemal puna am to,he
Contractors License law.
❑Iii naunder Sac LB&PCfor,hic,easnr
Dam
S COMPS
Owner` AIUELAON
/
• I herebyultirmtinder Witaltyof,equry one ofthn following declaration,: 0
0 1 have and will maintain a Certificate of Consent to self-insure for Worker's
CnmPe,oadun, as provided For by Section 3900 of te hLabor Code, for the
performance of the work for which this Permit is iscucd. O
❑I huvm end will maintain Workcr's Cninimnaniun Itwunlaca ooe requinW by Section
3701 of the Labor Cale,for the performance of,he work for which,his permit is
cued.Aly Worker's Compensation Iamrome carrier and Policy murmur are: _
Carrier Policy No.:
CERTIFICATION OY EXEM1 PION PROM WORKERS'
COSIPENSATION INSURANCE
(This section need nu,od completed it the partial is for one hundred dollars
(Elfin or less.)
I certify that in the rerfannanre of the.,,rit for which this Permit is issued.1
.null not employ Any Pe non in any mumter vo w m hcconm sunfce,10 file Worked
cman'rmfion Lows of Call firma.Date
Applicant
NOTICE'IO AVPLICANT'.II:after making this Certificate at Exemption,you should
hen,me subject m the Wo Etta',Cnmpensmion pmvisiom.1 the tuba Codc.You ntaet
O O 1'omhwi,h entody with such prnvlxioar or this pamnif shall be deenmd trotted.
FW CONS'IRucT ON LENDING AGENCY
a % I hereby alfimnha,there is a comsfmnion lending Agency I n'he perl'ormmnce
W of the work for which this Permit is issued(Sec.3097.Civ.C.)
IS A Lundcr's Num,
Z Lender'.Address
U 0 1 ccoily that l have read this uppl kation and.line that the maws infnrnm,iun Is
fs P correct.I agree to connply with all city and county ordinances and xmte laws relining
O t, mlwi lding ell O,O,limre
..and behy anthnim cpreunmdvan of this city, ,mer. ,0
y) ,he Axw,mendonN property for inspection joins x. n
.trt C6 We)agree vet vase.i ndemai fyand keep harmless the City of Cu,enino against
VJ liabilities.sequences,coax Iced grarding ouc<w etar may in any way L N0 ugxina said
V r7-i
City in ANTUNDERSTANDS A Aof ND
Petard.
SOURCE RELULAND WILL COMPLY WITH ALL NO NT Issued by: Dale
SOURCE REGULATIONS 11 p
O
Signature of App1nam/ConnaetO Uwe Re-roofs
I IAZARDOLS MATERIALS DISCLOSURE
Will the apellart or more bnddlna oe,upm,e,o.cor aide hfowdoae to feral Type of Roof
m defined by,he Cupcniou Municipal Codc Chapter 9.12.and the Ileelth and Safety
Code,Section 25532(a)'!
ore. \-�,No All roofs shall be inspected prior to any roofing material being installed.
Will,hemmrehnBdiegocaipar,no,equpoenn adeeieca which If a roof is installed without first obtaining an inspection. I agree to remove
emit comwonx airconfortmrds as defined by rhe Bay Area Air Gach y Maras, car
Doorid?res N1. all
new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I have cut Ibc oo,nador..nlw,rlulx c,ii, aters under Chupmr 695 of the
California Health&Safety Code.Section.,25505,25533 and 25534.1 understand Ihm
if the building does not currently have a tenant,that if is my resrymsibilify to notify the
ne cupanl of,he m toremmats which roof be met prior 10 it4anno a or Cenilicme N
Occupancy Signature of Applicant Date
,�-
ownerormmhorn ,gen, Date All roof coverings to be Class "l3" or better
OFFICE