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CITY OFCUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
R.J. PEREZ CONST INC
PERMIT NO.
21943 LINDY LN LOT I
R'S NAME:
PERIM ISSUE DATE
MOSHE MENDELSON
10091 B
PHONE:
SANITARY N0, CONTROL NO.
(408)252-2797
ARCHREC IENGiNEER:
•
BUILDING PERMRINFO
BLDO ELER PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm Nat 1 an theated under Pmvuae of ChaP" 9 (commencing
with Section 7001) afDivision 3ofdc Business and Profession, Cade. and my license is
IseLI III nand cif S-ClQ(n0
ADD ELEVATOR TO RESIDENCE
Licam lass Lle.g
Dowy}{e Comm R n r o
c
ARCHITECTSDECLARA�F
1 undeduend my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I barony 'from that I am exempt from the Communes license Law far de
fallowing mason. (Section TOI.5, Business and Profession. Code: My city or County
which require, a Permit to conduct, after, hamve, demolish, ver repair my Imnum
pilar u its issuance. alms mquim den applicant par such Permit to file a signed aummcnlValuation
Ueewc Law (chapter 9
Sq. Ft. Floor Area
that he is licensed pursuant to the previsions of the Conmcmrs
(commencing with Scedon 7000) of Division 3 of tha Businwand Profaning Code) or
$30000
Nat be is exempt thetefmm and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
APN Number
Occupancy Type
not marc man five bundled dollars WWI
❑ 1, as owner afore property, or my employee with wage as their sale eompeamdon,
Required Inspections
9 P
will dothcwark mdthemmnutetsnotimndedoroRered foreale(sm: 70N,Busines
and Profession Cade: The Conuacmes L immsas Law doe oat apply m ser Buser of
property who bui Ids ec ire pmts thermn, a nd who does such work himelf or through his
oununployees, provided that such improvements are at intended arartued foraak. IL
however, the building or improvement is mid within one year of mmpledon. the owner -
builder MH have the burden of moving that he did ml build or improve for purpose of
nfu.).
Q 1, as owner of the propeny, as neclwively eonbaming with liaised rommnoms as
conuuct the poject (See. 7014, Business and ROlsom aw Code:) The Conummra U.
eche Law doe not apply to an owner of property who builds or improves thereon. rod,
who contracts for such projects who a conuactor(s) licensed pursuant as dm Contractor's
License Law,
❑ I oro exempt under Sec BB P C for this recon
r Dau
WORKERS COMPENSATION DECLARATION
1 bemby air= under pnully of perjury ane of the following d"Imethe:
❑ I have and will maintain acuNBcau ufcoexat o self•inure fnwoftea Compn.
ation, u provided fn by Section 3700 of the Labor Cade. for the prformmce of the
were for which this perch is issued.
❑ I have and will mafinein Workers Compensation Insurance, as required by Section
3700 of the Labor Cade, for the prfarmmm of the work for which this Permit Is lewd.
My Worker's �Carol..edan 1 nme carrier ase Policy number me:
Cartier. 4b PrK - r d Paltry No.:
T
d �v
CERTIFlGTE OF EXE MP IONFROM O
COMPENSATION INSURANCE
(This suction need em be completed if the Permit is fn ane hundred do0us ($iW)
ser less.)
1 certify that ire the performance of the work for which this remit is Inwd, l mall not
,
employ anyperson in my manner m an to become subject m the Worleri ComperuNon
Laws of CARIORIiL Data
Applicant
NOTICE TO APPLICANT: If, after making this Cenificau of Exemption, you should
become subject an the Worker's Compensstion provisions of the Labor Crede, you must
formwim comply with Inch provision or this permit Shall be deemed Invoked.
CONSMUC ION LENDING AGENCY
I hareby affirm UW mem is a construction funding agency for the perfarmuue of
the work for which this, Permit is issued (Sm. 3097. CW. C.)
Ladcra
Landers Add.
5 1 certify that 1 have and this application and auto that the above information is
moccl.1 agrte to comply with all City and county ordinances and sum laws rehting to
building construction. and hereby a Louire tepamntaVm of this city to enter upon the
4 ahovomcntwmdproperty far inspection purposes.
1. (We, agree to save, indemnify and keep harmless to City of Cupertino against
O lia,Iid menu,cosumd expenses which may In any way accrue agaimosaid City
of~ It.
I m the
n ^
segwtce granting
PLICANT U DERSfANDS ND ILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUR EG UPON
—�
T ob
Re -roofs
Type of Roof
Sigmaurs, oflApplicaux'Comumi Dau
HAZARDOUS MATERIALS DISCLOSURE
Will to applicant m future building aaupmtsu e or handle haaardow maudal
an defined by the Cupertino Ma *0 1 Cock, Chapter 9.12. and the Heshh and Safety
1c, Scnion25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
Ya o
If a roof Is ins[alle •[hoot first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit haardnua airconuminants an dcflmd by the Bay Area Air Quality ManaScmenl
DistdcB
❑Yea
I have mad the hwnNmsmatcdals aquiommuumkrCapur6.95ofthe Califur.Tia
=Applicant
a ,SaUmu2550 vamlzss34.lundcmmdmcifhebuildingrotcurmnd
ve a enanl they ism penihilitymmdfy me occupantofme
quite cis tchmwlbemctpdo vain ea I.cenifiaearomnpancy.
Date
All roof coverings to be Class "B" or better
owns a monad.. d hag Bae