04040159 - CITY OF CUPERTINO ` `_= "-'" '' "'-' sw y.yy, A yy�a,� `
BUILDING DIVISION PERMIT z4CO RAC'TOR IN 'UY MJ�.TI - �_
BUILDING ADDRESS: PERMIT NCO 4 04 015 9
22751 MERCEDESV
OWNER'S NAME: PFRMITISSUEDATE
KIRSTEN VIN-CHRISTIAN & PA CAL'
NE: SANITARY NO. CONTROL NO.
ARCHITECffENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u o o LICENSED CONTRACTOR'S DECLARATION
I immby af11Am thm 1 am limnsed under rovisions of Cb'nor 9(commencing lob Description
n� with se Cl,�s��tMg))ofDivision 3ofthe Bu dProfess' sS ode.entl mylicense is gk
,a, imm�mrgx�aherrect. Sl ADD 202 SQ. FT. (2ND FL. ) gy�.ls{i,
v�2 Licentt clew Lic,x
a' Dak convenor CONTRACTOR: LAZZARINI CON TPJ 904)
I � CHITECTS OECLA N
underalend my plans shell W used a puhli recnrda
iGy
NOV 2004
Licensed Professional
3 OWNER-BUILDER DECLARATION
Com oto
i 1 ... affirm Nm 1 am exempt from the Cmnwcmr's License Lew for the
followpO whichingenes. (anion ]f131b,Businessand Improve,
demolish.
Code:Any city scounty111111 DINIrp
which requiem a pewit m cnnswcl alter,impmw,dcmclixh,nr repair any xwclum
Hy prior in its issuance,also requires the applicant forsuch permit to file a signed statement -
�0 that he is licensed pursuant to the pmmlouofthe ContractssLicense Law(Chapter 9 Sq.Ft.Floor Area 0
(commencing with Section]000)of Division 3 of the Businessand Professions Code)or
y that he"exempt therefrom and the basis for the alleged esemptlon.Any violation of
Section 7031.5 by any applicant for a permit subjects he applicant to a civil penalty of APN Number Occupancy Type
not more Nen five hundred dollars,($500). 342440038 . 00
0 1,u owner of the property,m my employees with wages u their sole compensation,
will do the work and the structure is not balanced or offered for sale(Sec.7044,Business
and Professions Cod c:no Contractor's License Law does not apply to an owner of Required Inspections
propenywho Wildsor improves thereon,endwho daessuchworkhimselforthrough his
own employeus,provided thatsuch impmvenumblate not in ended oroRered for We.If,
however.Ne building or improvement is eoltl within one yeti of c prove f Ne owner
builder will have the burden of proving Nat he did not Wild or improve far
purpose of
sale.).
❑1,as owner of Ne property,am exclusively contracting with licensed contractors to
comwct the project(Sec.7044,Business and Profusions Code:)The Contractor's Li.
range law docs not apply b an no,of property who Wilde ar impmxms thereon,and
who cmntrans for such projects with a contractor(a)licensed pursuant to the Consulots
License Law. -
0 I am a.cMPt under Sec, B&P C for Nis Munn
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I haw and will maintain aCenificamof Coment N self-insum for Worker's Compcm
cation.
As provided for by Section 3700 of the labor Code.for Ore performance of the
work for which his Permit is issued.
0 I have and will maintain Workers Compensation Insurance,as required by Section
37W of the labor Code.for Ne performance of the work for which this permit is issued.
hyMy Workers C mpen ton Ingo nm carter and Policy number as
�W k CATEOFE%EMPIT OM WORKERS'
COMPENSATION INSURANCE
fruisxetion teed not hecomplekd lithe permh Is foram hundred dollars(SIM)
ar loss.)
1 certify that In the performance of the work for which Nis permit is issued.I shall nat
employ any person in any manncrsn as to become subject to the Workers''Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,oRer making this Cerufmam of Exemption,you should
become subject m the Worker's Compensation provisions of the Labor Code,you must
0 foMwiN comply with such provisions or this permit shall be Accrued revoked.
Z.~NsCONSTRUCTION LENDING AGENCY
[�+ thereby oMo.that there is a construction lending agency for the performance of
C;1! be work fur which this permit is issued(Sec.W.Civ.C.)
WW Q Lender's Name
7 z Lender's Address -
U 0 I certify that I have Asad this application and sue but the above information is
{2u F cows.1 agree to comply with all city and county onfinances and sum laws relating to
DU building construction,had hereby auNonsa mpresema fives of Nie city an enter upon the
ehove-memioned properly for inspection purposes.
4 (We)agree to sew,indemnify and keep harmless ths City of Cupertino against
to Iiabilbbo.judgments,case and expenses which may In tiny way acerae against said City
W 7 in consequence of the granting of Ibis permit.
�i APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO POINT Issued by: Date
SOUR R LA ONS. Qjy
C7 Re-roofs
sit roof ApplicanUComractor Dak
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the,applicant or future building occupant store or handle h4ratd0aa material .
as defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Code,Section 25532()? All roofs shall be inspected prior to any roofing material being installed.
0 Yes X.
Will the applicant or future building occupant use equipm ret or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it havardous air contaminants u defined by the Bay Area Air Quality Management' all new materials for Inspection.
District?
Cl yes No
I have read Ne huardnus mals rcquiremems under Chapter 6.95 of be,Califer.
nis Health&Sam yCade,Seedom 25505,25533 and 25534.1 understood thm tithe Wilding
docs not emend,hew a moat,that it is my meponulailiry,to antuy the occulbmt of the
Meet. nu 'chmusWmetpdortess fa Ccrate
heoft]pc emgy.� Signature of Applicant Date
nor or authorized agent �GG.•.•GGee�yLL��1l 1/i, /e1UDfam All roof coverings to be Class"B"or better