06020047 �'
BUILDING DIVISION PERMIT �N".CRA- �TQR I14R,'.. ATIQ!1�1
BUILDING ADDRESS: PERMIT NO.O 6 0 2 0 0 4 7
21839 LOMITA AVE
OWNER'S NAME: PERMrr ISSUEDATE
GARY LI
E: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 . t�
:pg LICENSED CONTRACTOR'S DECLARATION lob Descr3 tion
u I humby affirm duet 1 m licensed under provisions of Chapter 9(cemexcha ng P
?zj wird Sadon 7gM1)of Dolsion 3ofae Business and Profeaaloru Coda.and my H".is
infullforceandelrect 1 SFDWL-2 STORY 3567 ' /GARAGE 480 '
Lieerra Lle.I
a-p Data Com,wur N ff eJ RF:
7W ARCHITECTS DECLARATION
I U
[turnaround my plans suit he used as Public records
s
'o LiameaPmresvarW
OWNER-BUILDER DECLARATION
I heresy affirm Na 1 m rumps from d r Canary Co :My c law for the
oo which raddason.(Sait Mecumnam,ancumdve.deiom Cmle:Amyehy or county
5$ whirs its Issuance.
ss a a permit m eerer Me ailir.opproapplicant
Orad deter h or repair any strunure
-z0
prior=iuiensedP.alwmquithetrovimosofthrauchpermrrofiba Signed
Aw(Chmmenl Valuation
< tuihee licewodpumwntotheprovisionsof ftComtumraUcevelaw(Chapter9 Sq.Ft.Floor Area i G (commencing with Section70(s))and tof he Division r of Wholed eta and pilon r y vials de)or $791719
e R g this k u rumps lurt(rom and to bob for lu dk{W eampdm.Any Nohtlan of
Session 7071.5 by any applicant for a permit"teas Ne aPiricaut in•civil Penalty of APN Number Occupancy Type
not mom Nan five hundred do1Ws(M).
❑1,M osvar of tha property,w my mploym wird wages u Nes rolecmpewdon,
win&Lhcwwk.md Nesw =u wtamndcdwnRermmraaa(Sm.] .Budexam Required Inspections
and Professiam Code:The Cnnmemrs Licerue Law does not apply m an owns of 9 P
property who Wildswimprovea Shawn,andwhodoessuchwork homelier through his
awn employ=,provided that such improvements am wt immmaed woBered foesale.IL
bowever,the building orimprowevent issold within ane year of eompledon,the owner-
builder will have the hurticn of p avins that he did nut build or Improve for purpose of
sale.).
❑1,as Owner of the property,am eulueively eanttacting with Ilce rand candatma m
convect the project(Sec.7014.Business and Professiam Code)Tu Communes U.
w =
ewe law does apply m an owner or property,who builds Or Improve thereon,ad,
who contracts fat such projects with a conwcmr(s)licensed pursuant to de CmunscmYa
License Law.
❑1 as exempt under sec. ,B&P C far this maven
r Dam
WORKER'S COMPENSATION DECLARATION
I hereby same under penalty of perjury asses of the following dedentiom:
❑I haw and will maintain aCerdOceu of Conant m elf-Iesaro for Work esCompm-
sation,a provided Inr by Section 7700 of the Labor Code,for W perfonnaae of the
wark foe which this permit is Issued.
❑1 haw and will maintain Worker's Compensation Imre aret,a required by Seedon
7700 of the later Code,foe the performance of the work for which Nis perms b iaucd.
My Workees Compmsadon budarm.e artier and Policy number art:
Carrier. lfl7� Policy No.:D O0`11 lOa 6
CER11FICA OF E%EMMON FROM WORKERS'
COMPENSAnON INSURANCE v
(Ibis seed=droll Out be completed ifIbe permit is find=hundred dullasa(5100)
or lean)
1 o niry Net M Ne pturman nco of the work foe which this permit is Woo,l lull nc1
employ anyperion In any answer an a m baoma sublets in the Watken Compensation
laws of CAMOMIL Data
Appllcm
NOTICE TO APPLICANT:If.arm,making Na Corina=of Exemption,you should
bacteria soot=in the Wohrts Compcwdon provisions,of the Labor Cade.you moa
.J O raMwids comply with Inch provisions or Nis Permit Nail o dcemcd muted.
z► CONSTRUCTION LENDING AGENCY
[.r I oreby affirm this dart U a construction boding agency for the pMarmana of
a � the work for which this Permit is issued Scc.3097,Civ.C)
W� Leaders Name
2 Landers Address
U O i oat fy Nat 1 have read this applicadon and rum Nat the move Imermadun Is
V.P corecL I agree in comply with all City and County aNiOaMO and faro bora misting m
OU building construction,and hereby autbodu representatives of this city to enter upon tis
W aovomendnnnd propernts.co for inspection exexpenses
purposes.
gy (We)agree to save,indemnify and kap hamlets the City of Cupertino against
U Z inconsetra dementeeasuand expewawhich mryln mywyurnca{alMtsaid City
(„)z APLICA nce of UNDERSTANtrarming ofDS
Nb permit.
m.t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEcULATIO S.
C Re-roofs Z—
s —ApPI�HAZARDOUS MATERIALS DISCLOSURE desi
Dmm Type of Roof
Will the applicant airreturn Wilding occupant Slone w handle hmatdow mamas
as defined by the Cuperina Municipal Cade.Chapter 9.12.and the Health and Safety
sac,Soetiom255324)7 All roofs shall be inspected prior to any roofing material being installed.
oyes
Will the applicant or future Wilding Occupant use equipment air devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harardnus air contaminants a acnned by tha Bay Ama Air Quality Management all new materials for inspection.
DistrisO
❑Yes No
I haw mad the hauMusmamdab requirements underChap ar6.95ofthe Celifor.
as Health&Safety Cada.Sadw25305,25533 md25534.I understood thetlf the Wilding
am Out normally how a urns,dent It is my ma mnaidity in neury tie accupmt of this
mquimmcn whbhmusthe metp. rut. ofACerdtle rep OceuPmcy Signature of Applicant Date
I Y�S
Owner Ihoriud agent Dam All roof coverings to be Class "B"or better