05070085 CITY OF CUPERTINO : ' 'r P + "1 .ani, w` *..
BUILDING DIVISION PERMIT WONTRAC�TOR`INFORMATION ��.
O UILDINGADDRESS: LNB CONSTRUCTION, INC PERMIT NO.OS 070085
11 WS NAME: PERM]T LSUE DATE
E: SANITARY NO. CONTROL NO.
(415) 585-3884
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
woo LICENSED CONTRACTOR'S DECLARATION JobDescription O O O
u 1 Mosby affirm that 1 am licensed under Provisions of Chapter 9(mmmcncing
`a with Succi. 7")af Di "on J or the BusizV and sett d cony Tit.is
�'� in mumme.naer c. O $18 ' 2ND STORY ADD-3 BEDRM/2 BATHS
?q= Liccvc�Lic.N $
ConDECt ^P� ' REMODEL—KITCHEN/ENTRY/BATH/POWDER RM
,e suuyu�� s shall N used
ATION
y�< I understand my plans shed he used u public records '
n
LLo
Licensed Pmfcssioml
^
OWNER-BUILDERexemptDECLARATION
d i I michy.(firm on 1 em exempt s a Ne lessons is t:Any c law for the
S p O follwhich re massa.pernit O 703 onL5.Business and rn.de um COM:Any City or county
y_ which myuiro a Pmmit is coma tht, aper,improve,dcmolW,fie a sig any tariclmc
r Z< prim m its l issuance,.. mquims Ne applicant for such perming rte se,Law statement
Nohe me licensed purstion7 h)of Division
of NCContmcessand cnulaw(Uhiler9 Sq.F[.Floor Area Valuation
e�$ UNIL he s exempt
diectien T ad the
oivrmf r of the Business ame and Poicon.Any
vi coon or $255954
Nat he u campy therefrom and the beer it the ctLegrA exemption.Any violation of
Section lours by toryapplicant for apermllsubjectaNeapplicant toacivilpenalty of APNNumber Occupancy Type
any mom Nan Rr<hundred dollars(ssofi). P Y YP
Lu mmeraftie peanus remYemploym wiNwaguatike(talc compewness
will Pr Newars_end the he oroffired Law does not
To(a,Business
and Professions code:The mtherson,and
who law doe,nay apply to an owner of Required Inspections
Own enywho huildsorimpmmethemogandwho rum encswart himselfedthroughWe his ..
Own employees,provided Natsuch impmsemenca am not inleMed m offered for Owner-
builder the building burden
impmmmentrsold within one year of impm or the ower-
builder will have Ute burden of proving Nn he did soy build or impmm for purpose of I�a[�\,\I
son.). FI N tl KYLE®
❑1,as owner of drc proi am exclusively contracting with limned contractors to
Caseconstruct it not(Sec.nBCC,Busowner
of and Property
who Professions Code:)The Conmcmr'a d
ccou law coca not apply to an owner of pmpenY who bunds or improves thereon,and.
whocontractsLace for such projects wiNacontraclor(q licensed Pursuant to the Canuactats rs a 200.a
LKCM1m TAW. Mill 'j.�J b
am exempt under Sec. ,B&P C for this mean
ar Dam BUILD fid p
WORKERS COMPENSATION DECLARATION [L.ff C✓�J_
1 hereby affirm under pcvlyy of perjury one of the following declarations:declarations: 1�.'Aq�rVIG�i
C3l ham and will maintain a Cerlirieam of Consent m ulDimu ,fm Workees Compen.
raison,a Frivoled for by Section 1700 of Ne labNPerformance or Code.for e perfoance of the
work for which this permit is issued.
❑1 pave and will maintain Worker's Compensation bssurums.a required by Section
171 of the labor Code,for the performance of On work for which this Permit is issued.
My Wor rnnsmionJnsun1n nrtim and Policy nu r
Cartier: ` Nl Policy No.: 0V0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thr section need not tic cmnplemd if tie,Permit is Intent,hundred dollars(SIM)
or leas.)
1 certify Net in the performance of Ne work for which this permit is issued.I shall not
employ any person in any mannerso as to become ubjca to dre Worker Compensation
Laws of chifomia.Dam
Applicant
NOTICE TO APPLICANT:Ir,after making this Certificate or Exemption,you should
become subject to the Worker's Compensation provisions of the labor CSM.you most
.J O fomvi
rthwith comply with such Pssoa or Nr permit shall he domed revoked.
'z rn CONSTRUCTION LENDING AGENCY v
l hereby aRrtn that Nem is a comlrt inn Lending agency for the Performance of
a >
he work for which but,Permit is issued(Sce.5099,Co.C.)
ap Lenders Name
a.z Umber Address
U C) 1 certify that I ham mad thus application and scale that the abase information r
Iy r COMCCL I agme to comply with all city and county ordirunces and sum laws miming to
building construction,and hereby annuim mpmaCmativea of this city to enter upon the
above-mentioned pmpeny for inspection Puryoua,
F y (Wt,)agree to save,ind nrfy'and tech nt,n ss City of Cupcnins against
fq liabiliti(we) 9.to cads.and x which mayinan ytya opentnoa City
V Z in consequence of Ne gra t f i Permit.
r-y APPLICANTUNTIONAN i WILL COM ITH LL NO P NT ssuedby: Date 9=D
SOURCE REGULATIONS. .(
�` � Re-roofs ?�
Signature or Applica Xontrxmt Oa
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dre applicant or future Wilding occupant store or Mndlc Wudsus mochal
dertncd by the Cupenine Municipal Code.Chapter 9.11,and the Health and Safety
.Scene,zssyz(a)?
C]Y., All roofs shall be inspected prior to any roofing material being installed.
IT#lo
Will Ne applicant or frutum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit ha>ardous air Coolant nu se defined by the Bay Area Air Quality Management all new materials for inspection.
Districrl
❑Yes Nu
Ibam read!the hmardsusmaunals mi incmenu under Chapter 6.95 oldie Califor.
nr Hesh&Safety Cade-,ScelopSl M5,25577and255M.IundersuM i b. ding
deea n e mlr ham a am t, t iI r my mspumibility to awry the .Pam f be
require oris himmost be t anaiafan or-cerdraleef up Signature of Applicant Date
owner or Norind agent Dale All roof coverings to be Class 'B"or better
c: