02110068 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
nUIES :INDY LN A PERFECT CLIMATE PERMITNO2110068
owlQ)+jf 1RPE:& LYNN LEE 10570 S DEANZA BLVD APPLICATPliS�UWY2002
IFONE: 408 861-9545 SANITARY NO. CONTROL NO.
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
�00 LICENSED CONTRACTOR'S DECLARATION
j 1 herchy grim that I am licaused under previsions of Chapter 9(Commercial, Ft3RNA0E RAE - ll
1 tlOn
with Section 7(1(10)of Division 3 ofthe Businesrand ProfessioreCale,and my license is � /7
in full forco and effect. .\
Z O re g License Class Lk.N
o�—pp Dem Contractor ` Y
W As mail use DECLARATION winds ppp(((JJJ
7❑ I untlersunJ my plans shall M used u public rccmds
0 Licensed professional �
OWNER-BUILDER DECLARATION
enc
r�i f 1 hereby affirm that I em exempt from the Cnnuacrnr's License Law for the $2847
w_00 following reawn.(Section 7131.5,Business and Pndessions Calc:Any city or county
s°'$�i which requires a Permit to construct alter,improve,demolish,or repair any structure
prior to its issuance,also reyuirca the applicant for such Permit o file a signed statement ,,,�
F that he is licensed pursuant to the previsions of the Contactur'a License Low(Chapter 9 ""'N@t4IFIddBA@9 Valuation
$ (commencing with Section 7(XXq of Division 3 of the Business and Professions Code)or
Wt be u exempt therefrom and dm basis for the alleged exemption.Any violation of
Section 7071.5 by my applicant for a permit subjects the applicant to a civil Penalty of PN N Occupancy Type
nut more than RK hundred mllsre(ssoo). 303 — ROUGH MECHANICAL
❑I,as owner of the property.or my employees with wages as their sole compertsation, B04 RG H
will do da work,and da structure isnot intended or offered for We(Sec.Todd,Businessp�yyp
and Prefessious Code:The Conmacmff License low does not apply to an owner of 505 — F I NALgtons
property who insulator improves thereon.and who does such work himself or through his
own employee.provided that such improvements am not intended confuted for aide.If, 507 — FINAL PLUMBING
however,the Wilding or improvement iasold within one YearofmmpmBen,the comer- 508 — FINAL MECHANICAL
Wilder will have the burden of preving that he did not build or improve for purpose of
sale
.as owner of the progeny,em exclusively emumbe ng with licensed em racmn to
true,the pmjec,(Sec.7044,Business and Poofessions Code:)The Conuecmrs U. _
cause law does not apply to an owner of property who builds or improves themon,and
who connotes for such Projects with a conmacmr(s)licensed pursuant m the Convector's
I Law.
em exam t under Sec. B Q P C for this mason
I�I N n C 2 a c% v ii—sr s�
—1W0 KER'S MPENSATIONDtii`-
1 hereby,aRrrn under Penalty of perjury,one of the following declarations:
I ham and will maintain a Certificate of Consent to self-insure for WorkeesCompen-
sation,as provided for by Section 37M of the Labor Code.for the Performance of the
.,it for which this permit is issued.
❑1 have and will mainuin Worker's Compensation Insurance,as nurtured by Section
3700 of the Labor Code,for the performance of the work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEM Pr10N FROM WORKERS'
COMPENSATION INSURANCE
(This section need not bu compicmd If the pmmit is foronc hun&cd dollen(SI(X))
or less.)
1 certify that in the Performuice of the work for which this Permit is issued,I shall not
employ an nen m pparrs gq� c soli no dm Wmken'Com satiun
P Y Y Y jn1 1o0 r'1 QeV�ec Kn
Laws yf tali a.bete
NOME TO AP I a f,Compression
this Cisims of of Exemption,abdyou should
becomesubjectto the urh ro Coosor this provisions of the Lobar Code,you must
O z forthwith comply with such provisions or this Permit hall he deemcJ rcvakcJ.
z O CONSTRUCTION LENDING AGENCY
(—t I hereby affirm Nat there is a construction lending agency for Ne performance of
ai 7
the work for which this Permit is issued(Sec.3IP7,Co.C.)
QLenders Namc
z Le ders Address
U 0 1 certify that 1 have read this application and sum that the above information is
lL F correct.I agree m comply with all city and county ordinances and state laws relating to
DU building construction,and hereby xuthonze representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupenum against /
jj liabilities,judgments,cuss and expenses which may in any way accrue against said City
U z inconseyuenccoftbegraminguf Nis permit.
..a APPLICANT NOERSTANDS AND WILL CO WITH ALL NON-POINT' Issued by: Date
SOU CE G LATIONS. ,0
Re-roofs
SignatureolA icanUCnnnactor Dam
fiAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant ser ilium building excupanl store or handle he bdous matcrisl
s defined by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety
crNe.Secif n 25532(a)7. All roofs shall be inspected prior to any roofing material being installed.
❑Yea
Will the applicant orft tobuilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as deducd by the Bay Arca Air Quality Management all new materials for inspection.
Distria7 r
❑Yes 9k,
1 ham rtaJ the haraNnus marerielsmyuiremenu under Chapter fi YS of the Califory
niaflcaldrds Safety Coda Sadmss2551)5.25533md25534.Iun4mm�d Nvifft building
Jms not currently host a¢rant Nat i,is my rcsrysmihilityto notify the oecupenr of the
mquircmems hichmustlnmet riertuiaanamm�ftCerdrato Ocmpancy.� Signa[ureofApplicant Date
wncrur ho zedagc Dam
All roof coverings to be Class"B" or better