05040034 CITY OF CUPERTINO �^
BUILDING DIVISION PERMIT ,CONTRACTQRNF30RMATIO
BUILDING ADDRESS: PERMIT NO.
LEWIS JOHN H AND MARCIA J 05040034
OWNER'S NAME: PERMPI ISSUE DATE
E: SANITARY 0. OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGEIECT PLUMB MUCH
0 E 0 0
LOp❑ LICENSED CONTRACTOR'S DECLARATION
Wb I thereby affirm that l am Hemmed under provuiom of Chapter 9(commencing Job Description
�y with section]1100)of Division 3 ofthe Business and Professions Code,and my license is
n�H I r \
in full fore and effnm.
j gyz License Dant Lc.If INSTALL GAS FIREPLACE'S/BUILD SOFFIT J
Z—E Dme cam"`mrAFTER FAMILY ROOM CEILIN�
iW ARCHITECrSDECLARATION
u i7I understand my plan shall W used as public records / t
Dieu
''C Licensed Pndcssionel
3 Oat I am exempt
from
DECLARATION [[[���
C I hereby.(firm that 11. exempt from the Contractors LiAny c law for IW
p O following mason.(Saito]construct.
B.alam.i and Professions Coale:Any can m county `t�T r Itll`s➢D)]
m which riyus u n e..bare cnnswcL aluy bnprow,deermit t fie.signed
igany swmurc
Fly dom he i t issuance.p..requires the thovisio ants;of for sarch Contractor's
to file. Law(chapter
< (c numencing red pSection to the provisions;of the Conuacmr's ul Professions
roflaws Cook)r9 Sq. Ft. Floor Area 1.t9(AOA981
,H$ (commis exempt
Section and the
Division]of al a ed!cssantl Prefeu vi Cook)at X71 b
that he u exempt IWrefmm and Ne emu for the alleged exmpdon.My vioWuon of
Section 7031.5 by my applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy Type
not more than five hundred dollars($500). P Y YP
❑Luownerardu propsssr•amr emDloyw with wages a:Ilvirxle cmnpensstion, 32619072 . 00
will do IW work,and the structure Is nolinunded moff o d hustle(Sew 7014.Business
and Pm2uions Code:TW Commencer License law does not apply th an owner or Required Inspections
property who builds or improv thereon,and who deressuchwork himxlforthrough his
own employers,provided that such improvement arc not wounded conferral for We If,
however,the building or improvement is said within one year of completion,the owncr-
builder will have Ilse burden of proving Nu W did nom Wild or improve far purpose of
.it.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
comtnct the project(Sec.7044,Business and Professions Code:)M Contractor's Li-
cense law nes not.pp y t e owner Of PTpgy'vho Wild of..t toorproy Conw .ea
who conhc far A/d 'ec iNaca raE�or )Iicenxdpuravanno the ConvutoYa
'we. (/m
❑1 c m ,B&P'citadmisrc^t(on
Ow Data
WORK '$COMPENSATION DECLARATION
1 hereby elrnm under penalty Of perjury one of the following declarations:
Ix and will maintain•Ccnificau of Consent x til(-imam for WartefaCompcn-
n,ss provided for by Section 37M of the labor Code,for the performance of IW
work for which this permit is issued.
❑1 ban mod will maintain Worker's Compensation Insurance,as,required by Section
3]00 omni labor Code,for the pertmmana of the work ferwhich this permit is issued.
My Worker's Compensation Insurance canner and Policy number are:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE
(Thu rection ntttl ret he completed if the permit is Amoco hundred dollar(51011)
m thss.)
1 artily doom
nee c or
fo Ni permit u issued.I shall nut
employany rso ran n s sub' othe Workers Compemaom
Laws Of Cali r' D
Applicant
NOTICE PLICA If.of-r making Nu Ccniftcvu of Exemption,you shoulJ
baome, jecl m Ne Worker's Campcnsation provision,of Ne lahm Codc,you must
.J O I.Mw comply with such proviunns or Nu pefmim shall W deemed rcwkcd.
Z 7 CONSTRUCTION LENDING AGENCY
'r+� Ihereby affirm that them is a construction lending agency far the perfonnana of
C.�. thc wort for which this permit is issad(Sec.3099,Civ,C)
Q Lenders Name
r7 Z lenders Address
U 0 1 cenify that 1 Mw read this application and stat that the show information is
I,, " correct.I agree to comply with all city and county ordinances and state laws relating to
0 Wilding construction,and hereby mo0orim representatives of this city to enter upon the
IV) .how-mentid,one. coy for inspection puryo may
LL (We)agree to taw,iml.doofY and kap let the CtIY of Cupertino against
z livbi' Judgmcn and,xpemcsw ' may nany way accroe against said City
U� In MC C II O(thi1 it.
PLI ANT N R S WILL MPLY WITH ALL NON-POINT Issued by: Date
S U A
_ Re-roofs
r gnmurcolApplicaHAZARDOUSMATERIAISDISCLOSURE nor Dau Type of Roof
Will the applicant or future Wilding occupant mom or handle hazardous material
m defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
ode,Sccsion 23572(a)? All roofs shall be inspected nor to an roofing material being❑Yes �� P P Y g g installed.
Will the applicant or future building occupant use equipment or dcvicm which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air contaminant u defined by the Bay Area Air Quality Management all new materials for inspection.
f ct?
Yea
an ardonsm eels uiremcnta under Chapterti.93ordecalirm-
nia cal & ely d 5505, 33and25534.1undcrsundthvifthe Wilding
J t c ml L Nal i my responsibility to unify the occupant of the
n err atones NcnacytiEca am'pmm Sig nature of Applicant Date
wneralamhndxdagent 4 OD,x All roof coverings to be Class "B"or better