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09070208 REV1 i CITY OF CUPERTINO BUILDING PERMDT ERMINED PERMIT NO:09070208 CONTRACTt)R:TBD-TO DATE ISSUED:03/23/2010 „DING ADDRESS: 10128 LEBANON DR PHONE NO: 'R'S NAME: CAROL ELLIOTT ;vGR'S PHONE: � �,-,- ' DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB LICENSED CONTRACTORS MECH T_ RESIDENTIAL COMMERCIAL Lic.# ense Class VSN#1-PORCH AREA,MEDtA RM ADD Date JOB DESCRIPTION:R OPENING AT GARAGE. ntractor ter 9 WINDOW,(LOSE DOO iereby affirm that I am licensed under the provisions of Chap M,LAUNDRY,CHANGE with Section 7000)of Division 3 of the Business&Professions SFD ADDITOTOREP,IT�H ROMOFSTER SUITE,MEDIA )mmencing PLAT ROOF )de and that my license is in full force and effect. hereby affirm under penalty of perjury one of the following two declarations: have and will maintain a certificate of consent700 of the Labor Code,for the :ompensation, Provided for by Section 3 permit is issued. erformance of the work for which this permitiis Insurance,as provided for by EVao1kiOn1280000 have and will maintain Worker's Comp performance of the work for which this Sq_Ft Flt or Area: Section 3700 of the Labor Code,for the p permit is issued. APPLICANT CERTIFICATION APN Number:34214023.00 that 1 have read this application and state ordinances ands ate laws relating I certify I with all city and county to enter T STARTED correct.1 agree to comp Y authorize representatives of this city WORD,{IS NO for inspection purposes. (we)agree to save IT EXPIRES IF to building construction,and hereby mems, IT ISSUANCE OR upon the above mentioned p City i Cupertino against liabilities, ence of the PFR gIN 180 DAYS OF PERM SPECTION. indemnify and keep hazn' accrue against said City in con q WIT CALLED IN costs,and expenses which may applicant understands and will comply 1S0 DAYS FROM LAST granting of this Permit. Additionally,the app with all non-point source regulations per the Cupertino Municipal Code,Section pate: 9.18. Date Issued by. -,nature TION RE S' installed.If a roof is © OWNER-BUILDER DECLARA inspected prior to any roofing material being All ro ifs shone of all be insp an inspection,t agree to remove all new materials for I hereby affirm that I am exempt from the Contractor's License Law forinstal A without first obtaining the following two reasons: employees with wages as their sole compensation, inspe;tion. or my Date: 1,as owner of the property, Applicant: will do the work,and the stricture isnot intended or offered for sale(Sec.70 Signature of Business&Professions Code) contracting with licensed on actors to „OR BETTER .1,as owner of the property,am exclusively project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS construct the p ro J three penal of perjury one of the following 1 hereby affirm under p HAZARDOUS MATERIALS DISCLOSURer 6.95 of the declarations: require under Chap I have and will maintain a Certificate of Consent to set Labor re for Worker's I h ive read the hazardous materials req ter 9.12 and the health& ed for by Section 3700 of the Labor Code,for the rnia Health&Safety Code,Sections 2;505,25533,apte and 25534. [will maintain Compensation,as proved Ca iifo Chap Perm is issued. provided for by Cupertino Municipal Code, ensation Insurance,asp compliance with the Cup should I store or handle hazardous material. performance of the work for which this P Sa rety Code,Section 25532(a) 1 have and will maintain Worker's Comp perform of the work for which this ui ment or devices whichMan gement District I will AUditionally,should I use equipment Bay Area Air Quality Chapter 9.12 and the Section 3700 of the Labor Code,for the p Cupertino Municipal Code, permit is issued. permit is issued,I shall contaminants as defined with the p maintain comp I certify that in the performance of the work for which this P Health&Safety Code,Sections 25505,25533,and 2553 . to any person in any manner so as to become subject to the Worker's l not employ this certificate of exemption, t ��;CllvComp rovisions of the Labor Code,l must fw� ateensation laws of California. If,tae station P g •�• become subject to the Worker's Comp permit shall be deemed revoked forthwith comply with such provisions or this p G� CONSTRUCTION LENDING AGoENC r the Performance of work's APPLICANT CERTIFICATION agency application and state that the above information is hereby affirm that there is a construction lending that I have read this app ordinances and sate laws relating for which this permit is issued(Sec.3097,Civ C.) 1 certify with all city and county correct.1 agree to Comply authorize representatives of this city to enter Lender's Name for inspection purposes.(We)agree to save to building construction,and hereby , non the above mentioned property of Cupertino against liabilities,judgmentsLender's Address Jemnify and keep harmless the City consequence of the TION g;; )Stsand expenses which may accrue against said City in the applicant understands and will comply ARCHITE T'S DECLARATION AdditUoa iolns per the Cupertino Municipal Code,Section tans shall be used as public records. ce reg 1 understand in pn �te Licensed Professional y L/