03080083 (3) CITY OF CUPERTINO err « T'iii5-.w 'A < r �r lis^
BUILDING DIVISION PERMIT xCON 'AiACT�R NFOItMATIO�L
BUILDING ADDRESS: ARTS I GNS PERMIT Nlb 3 0 8 0 0 8 3
OWNER'S NAME: 165 SAN LAZARO AVE PERMITISSUEDATE
KAAREN STREETMAN 08/18/2003
]ONE: (408) 245-7133 SANITARY NO. CONTROL NO.
ARCIIITECfIENGINEER: BUILDING PERMIT INFO
BLDC ELECT PLUMB MECH
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�Oo LICENSED CONTRACTOR'S DECLARATION
I Z C 1 hereby affirm ohm 1 am licensed under provisions of Chapter 9(Commencing lob Description
0(111
<U with Section] )nf Division 3 of the Business and Professions Code.and my license is
'may in at IV m eget. C4S 5C (o L(4te SIGN
ytjz Icer Lic. _
D m y pl Can
£7W ARCHITECTS RATION
f W dere and mm shell W u d puhlic Ards D
sot, Licensed Professional
`0 OWNER-BUILDER DECLARATION
<S 1 hereby affirm Not I am exempt from Ne Contractor's License Lew for the
O D following moon.(Section 7031.5,Business and Professions Code:Any city or county l I t
<m(< which requires a permit to construct,slier,improve,demolish,car repair any sbumum \ $7175
0;t'
prior to its issuonee,also requires the applicant for such vomit to file..signet summent "
that he is licensed pamount to the provisionsof the Contract.,',License law(Chopmr') Sq-Ff, Flodr A7rea Valuation
z G (nommancingwithSection70W)ofDivision3oftheBusimessandProfessionsCode)or 35717012 . 00
159 that he is exempt themfmm and the basis for the alleged cxernalon.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil tonally oI APN Number Occupancy Type
not mart than five hundred dollar.(SSW).
I,as owner of Ne property,at my employees with wages as their sale compensation,
will do the work.and the atructum i,not immad'd or offered for sale(Sec.7644,Business — dinspections
and Protestations Codc:The Contractors License lawms mdocs not apply to an owner of 10 3 - UFER
property who builds or improtheoa,and whodoe t such work himself or through his
own employees,provided that such improvements are not intended oraRered for sale.If. 104 — REBAR
however,the building or improvement is sold within one you of complcuon,the owner.
builder will have am burden of proving that he did not Wild or improve for purpose of 105 - ANCHOR BOLTS
"le)' 304 - ROUGH ELECTRICAL
E] 1.as owner of the progeny,am exclusively contracting with licensed contract.to 505 - FINAL ELECTRICAL
construct the project(See 7044.Business and Professions Code:)Tom Contractors Li
amu law docs not apply to an owner or progeny who Wilda or improves themon,and, 514 — FINAL PUBLIC WORKS
who contacts for such projects with a contncmr(s)licensed pursues to the Convectors
License Law.
0 l am exempt antler Sec. ,B&P C for th,...a
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury aro of the following declarations:
I have and will maintain a Carificee of Consen0o self-insurc for WorkersCaopen-
snion,as provided for by Section 3700 of Je labor Code,fm the performance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section
3706 of the Labor Code.for Ne performance of the work for which this peanut is issued.
My Worker Co rualjpplrmunn`ce carrier an o cy nuher art:
IM CERTIFICATE OF EXEMP 18N FROM WORKERS'
COMPENSATION INSURANCE
This satin.need not beemad.md Iran.permit Is fnfome hundred dollars(SIM)
carless.)
1 ccnify that In the performance of the work for which this permit is ladded.I shall mo
employ any person in any manner so as lac become subjecuo the Wormat Compensation
Laws of California,Date
Aildh ant
NOTICE TO APPLICANT:If,after making this Ccnifcam of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
7z forthwith comply with such pravistom or this permit shall W deemed Invoked.
CONSTRUCTION LENDING AGENCY
I hereby aRnm that Nem is a communion lending agency Income performance of
Y. > the work fur which this parmit is issued(Sec.3097,Civ.C.)
Q lenders Name
=z Lender's Address
J Q I ccnify,that 1 have read this application and sum that the above information is
y Fcorrect I agree to comply with ell city and county ordinances and stale laws relating Ire
V building construction,and hereby autharim representatives of his city to enter upon the
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above.mentioned property for inspection purposes. PPp
(W')agree m cove,indemnify and keep hart in an the City mCupertino against
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equncejudgmanu.theeostland ofpcnae9which may In any way aceNC against said Cily
J z IAncnnseque TeUNDERSTANDS granting of tANhis D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SODREW,REGQLATIAS.
C— SI f ° Re-roofs
Signawrc of ApplicanJCom 'tor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hacardous moralist
as dcfiad by the Command Municipal Code,Chapter 9.13.and the Health and Safely
Codes Section 25532(.)? / All roofs shall be inspected prior to any roofing material being installed.
Yrs PN
-
Will the applicant or future building ocoupant use equipment 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.
am"
❑Yes YbNu
I have read the huvardnus materials mquimmoma under Chapter 6.95 Oldie Califon
7�q'd
ll LiA'suferycode,Sections 255(15,25533 end 35534.1 umJersmnd that did.building
not currently have a Omani,that it is my respunsihility w amity the oceupat of the
lrcm hichmust metpnortoissuanceofaCardread,of2c j, .,Signature of Applicant Date
nor or atiat ri cu agent Dal' All roof coverings to be Class"B" or better