03020039 CITY OF CUPERTINO - �� --'
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION-
s
BUILDING ADDRESS: DANIEL MCNARY LECKRONE PERMITNO.
22701 SAN JUAN RD
OWNER'S NAME: APPLICATION SUB DATE
DANIEL MCNARY LECKRONE 02/12/2003
ZONE. SANITARY NO. CONTROL NO.
ARCIiM=ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECI
�00 LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 berchy affirm the,1 am licensed under provisions of Chapter 9(commencing P
with Section 700(o of Division 3 or the Business and Propositions Cale.and my license is
In full hence and effect, REPLACE WATER L E
License Class Lic.of
oZ—I Dow Contactor
G`mm=Q�Q�
ARCHITECTS DECLARATION
y 2 1 understand my plans shall be used as public recur t
2LLo Licensed Professional s
y OWNER-BUILDER DEC ATION 111
p u� E I hereby affirm that I am exempt from the a Lice law
R100 6 O C following reason,(Section 7031.5,Business and No tree de:AtI)(Y or my
X$_ which requires a permit te construct,alter,improve, modish, it re r sett stn - m
Fy prior m its issuance,also requires the applicant for sue rm11,fl hard tc rat iv.A
3o
that he is licensed pursuant to the provisions of the Co t dr7L' law a rH Sq. Ft. Floor Area $1VWation
,Sp$ (cnmmencing with Section 700)of Division 3 of the ess and Professions Code)it
3.• that he is exempt therefrom 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 Occupancy Type
not more than five hundred dollars(S50E.
❑ I,as owner of the property,or my employees with wages M their onto compensation,
will do the work.and the structure is nos intended or offered for sale(Sec.7W,Business —
SEWER
and Professions Code:The Contractor's License Law does not apply to an owner of 202 - UNDERFe lYl`/lki 4G
progeny who builds or impmva thereon,and who docs aitch work himself or through his
own employee,provided Natsuch improwmenls are not intended or adhered for sale.If. 301 — ROUGH PLUMBING
however,the building or improvement is sold within one year of completion,the mmar-
builder will have the burden of proving that he did not build or improve for propose of 302 - TUB & OR SHOWER
sale'1 502 - FINAL PLUMBING ENERGY
1,a Owner of the property,am exclusively contracting with licensed contractors to 506 - GAS TEST
co wet Ne project(Sec."IMC.Bnsiness and Rofeuions Code:)The Contractors Li-
censelawdaunotapplytomowtmrofpropenywhoWildforimpmws0mrton,and, 507 — FINAL PLUMBING
who contracts for such projects with a coneractor(s)licensed pursuant to the Contractors
License law.
lam eie in order Sec. B&P C for es won
WORKER'S CO PEN ATIOFTDECLAR APfON
�— Ibotany affirm undcrpenalty of perjury,one of Ne following declarations:
I have and will maintain a Cenificme of Consent to self-insure for Worker's Compcm
sation,as provided for by Section 37M of the labor Code,for the performance of the
work for which Nis pemo t is issued.
❑ 1 have and will maintain Workers Compensation Insurance,wo required by Section
3707 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carie, Polity NO.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is home,hundrtddollars(SIM)
or less.)
1 certify that in she Performance of be work for which this Permit is issued,I shall not
employ any Nixon in my manner se as to become subject o the Workers'Crmpeasation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcam or Exemption.you should x
become subject to the Workers Compensation provisions of the"hot Cade,you..It
�Z fonhwi th comply with such prseions or this permit ship l be deemed revoked.
OCONSTRUCTION LENDING AGENCY
[-+ I hereby affirm that there is a construction lending agency lin the perlormance of
C! the work for which this Permit is iasecd{Sec.3097,Civ.C)
W Q Lender's Name
]z Leaders Address
U O 1 certify Nat I have read Nis application and sate not the above information is
W P comet.I agree to comply with all city and county ordinances and sure laws relating to
DU building construction,and hereby authodm represenatiws of this city to enter upon the
W abnve-mentimad property for impection Purposes
(We)agree to save,indemnify and keep harmless[be City of Cupertino against
„y V) liabilities.judgments,uos and expenses which may in any may awac against said City
U z APPeof 0.tuarding of I
L CANTUN UNDERSTANDS AND WILL COMPLY WITH ALO INT Issued by: Date
SO R .REGULATIONS. 4W
Re-roofs
S urTOTApplicandContrue,tor D
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store nr handle hanrdous material
as defined by the Cupertino Municipal C<We,Chapter 9,12,and the Health and Safety
code,se[6on 25532(a)P All roofs shall be inspected prior to an roofing material beim installed.
❑Yes Na P P Y g g
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil hazardous air contaminants as defined by the Bay Arco Air Quality Management all new materials for inspection.
District?
❑Yes No
1 have read the havafdnus mamdals"aircments un@r Chapter 6.95oohe Califor-
niallealth&SafetyGak.Sections 75515,25533 and 255M.l understand if thebuilding
does net certainly haw a avant.Nat is is my responsibility to and M to of c
a virem,nta which must be mm prior issuance ora Ccaf to of Os y Signature of Applicant Date
Owrimof mttenimilagem ibat. All roof coverings to be Class "B" or better