00060051 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
Bun.DINC8I1)3ssLONNA LA FRAN LEE CONSTRUCTIO pi:10Gi000600,91.
OWNER'SITQAO AUSTIN D AND VIVIAN 20917 FARGO DR APPLICATO&V))4'W--2000
PHONE: (408) 996-2527 SANITARYNO. CONTNOI.No
P71.
O O ARCH]I'ECDIINGIN ER: BUILDING PERMIT INFO
z BLDG HIA4C'IPLUMB MIECH
F� I,ICIiNSHOCONTRACTOR'S DECLARNHON Job Description
3,K O ]
he
mrrnt tial I ala licensed under provisions of Chapter 9(commencing
with Semon 70100)of Division 3 of the Business and l`mfersinn,Code.and my license DEMO
6 m full force and effect.
�s`n2 .en C�t�• Lie.al
Date Carmine,
F=C g dersom l my pARCH I'I ECT'S DECLARATION ,
y�llans.hall W used as public records
d�C
m i p u. acus cd
Professional
a'y r OWNER-BUILDER DECLARATION
ce—to 1 hereby afMn than I am C®ntpr Gum the Coal acoria Llcensa Law for the
i-=< following emma.section 70315.Brones,and Professions Cole:Any ally or amnty
Ziwhich4 permit T c wet alter. p d Ii,M1 p: v small
pnort t . Iso it rM1applicantf such permit flsignedstamovenl
i 3 (hal he is live of parwnnun (he ecc,,uneot tile C lan,lor,l < 1 IChaplar 9 Sy. Ft. Floor Area �Iatltl l
wamnnneing with Semina 70gb of Division 3 of The lmsine,s and Profession,Code
car Thal he is e,empt therefrom and the basis for he alleged eacmptinn.Any vinmtion
of Section 703 L5 by any applicant for a permit subjects the applicant n a civil penally
of nm more mon live nm:dred dollar,(550(d. N&Jjotl 00 Occupancy Type
O 1.a,smmer of the Pro'Em"m eery employee,win wagcs-their sole compensmion. .
wiu ne Inc woe,and the ode ovenor is net hounded or named ole,me(S'fl,to r NO ASS I GNE1� CIMSPETEICIJUMS
Business and property
W ons Wild,
or improve,
eve,the e's Liana o d Jnsu not n lit au
orr of pmparw who milds lir improve aM1 such i and who encs such wed intended
through his own employees,)bided that such ve cal is
are not oin, Cd if
ounrnl for,ale.It,owner
haven the Fui Wing or improve of pow is Its,
within nuc year of
onprove for the ase of alldcr will hove rite harden of proving thw he Ed nun huilJ lir
improve for purpose of Hole.).
❑I,m owner of the p clan ,um exclusively occoarain,with Reused Cvolmnar,It,
Lomlmn the project(Sm.9141.In...ae,s mad rmfeomm.Cndep The Cnrumnnr', _
icense Law do,nut apply to an owner of properly who build,or improves themon., t .
:sod who contracts for such projects with a camrunm(U licensed pull et the
Convenor,Ulcn C Law.
01.,it exempt under Sec. .B S P C tin thin reason
Owner Date
WORKER'S CUMPFNSA'IION DECLARST ION
I hcrehy alhmt under penally of perjury,one of the following declarations:
❑ I have and will ,.,jdc n f CertificateIte of Cons3700 o Tosell ift,,m tae Wor he
Compensation, be provided fur by Section 371X) of The lalvn CWe, for rite `/v\
perfnnnance of @c work for which this permit i,issued.
❑I ase and will maintain Worker's Cu alsooninn Insurance,as re9uansl by Section
390(1 of the Labor Cole,for the performance of the work fur which this permit is
coal My Worker's Comic( lin Insurance carrier and Policy number am:
Cartier: No
Policy 1
C13RTIPICAI'ION OI EXEMPTIONliy FROM WORKERS' i
COMPENSATION INSURANCE
H his cairn need not be completed if The permit is lin one hundred dollar
IS I But or le".)
I amity that io the perlornance ni'mite work lin which dila permit is i„uud,1
shall not employ any Person in any manner so as,to become n.ubilect ht the W'odcv'
Cmnpcnation Laws of California.Dae
Ant,am ..
Sol ICETOAPPLICAN']111,alicrmmking this Ccnilicale of Filluelloa,you should a -
become subject m The Workers Conapansaion provisinns of rhe labor Code.you all
Q Q forthwith cnmPly with such provision or this permit shall W deemed revoked
Fy C6NSTRUCI'RJN LENDING AGENCY
> I mral affirm that then is a construction lending agency for the perfommmc -
uf the walk for which this pinna i,issued(Sec.3097.Civ.C.)
aQ Lender's Nmnc )
Z lander',Address
U Q I artily that I have read this application and sola that the uh Inlnrmminn 1,
Las (✓ er rivet.I agree to comply won all city and cormy ors ilaac,s and,tam law,elating
Q fJ mbuilding construction,osJM1 by titrepresentatives ITh ul,ty enter open
W the M t d p pe ty 1 inspection purl
-/
F Q., (We) g- 1 t Iy Jk ph I.:the wet fC I n agai no
said
V) Iiahll judgments. 'Ica I pc :. h h y any "Y '6 Inst said
(,7 G City in Cons4unn,e of the i mnnng of thi permit G 1
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by. Date
�'1�(�p}�F.GULAOUNS. '
'ignafure of Apphea""onimat Dae Re-roofs
HAIA RDOUS MATIiRIALS DISCLOSURE,
Will thuupplietmt lir future ballding teannantnmm lir handle hamrlbu,material Type of Rc
as defined by the Cupertino Municipal Cove,Chapter 9.12.and the Health and Safety
Code,Suchen 25532p i)7
Cl Yes 0N All roofs shall be inspected prior to any roofing material being installed.
Will the appiicamnr future Wilding occupant use equipment lir devices which If a roof is installed without first obtaining an inspection. I agree to remove
emit hazardous air contaminants as defined by The Buy Area Air Quality Management
Di"All? all new materials for inspection. Applicant understands and will comply with
❑Ye, 0N all non-point source regulations.
1 have read the lamm000s materials requi¢mcntn under Chapter 6,95 of the
Cahlurnia Health A Sul'cty Cndu,s,ocurn,25505,25533 unci 25501.1 w..f mond that
if the(wilding doe not currently hive a tenant.that it is my rai*msihillty to airily me
cupznt of the requiremcnns which muni be mer prior n issuance of o Cenihcac of
Ot"iwney' Signature of Applicant Date
�r modrm agent Dare All roof coverings to be Class °B"or better
OFFICE