07120270CITY OF CUPERTINO
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DIVISION PERT
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BUILDING
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TBD - TO BE DETERMINED
PERMITNO.
07120270
a'sUNAME:
PERMITISSUEDATE
LUTHERAN CHURCH OF OUR SAVIOR
05/16/2008
PHONE:
SANITARY NO. CONTROL NO.
ARCHIIECOF:NGINEER:
BUILDING PERMIT INFO
SFDWL-RESIDENCE FOR ASST. BLDG ELECT PLUMB MECH
O O O
LICENSED CONTRACTORS DECLARATION
^' ^' ^-- ^ ^ - ^ ^^ • •- ..Joh Description
1 busby ". that 1 w nxtuc l under provisions of Chapter 9 (cemmerming
with Section )q1U) of Division 3 ofmc Busircumd Pro)fe�ssiaons Code, ray liccme u
/an5d
in full torte andercec
Clay - -1 Loc. e
Charcc
Dela C
-S DECLA oc !
RC S DFCL
call x a
1 undermnJ my plain shall W reed as Public rmortk
Licensed Professional
,OWNER -BUILDER DECLARATION
1 hereby Maine used I am exempt from the Conaactar's Liecnw law for tW
following won. (Suction 70313, Busineu and Pcofestiom Cade: My city ne county
winch myuirm a Permit in mwnca simr, improve. demWhh. or repair any noncom
prior to its inuaee. also requires the spPlimi for such Permit to file a signed mmmust
Sq. Ft. Floor Area
Valuation
Nat W is licensed pumm(to 0w pnvisiha of the Contractor's Liceve Law(LTapter 9
(commencing with Section 7000) of Division Sof the Business and Prefessioru Code) Or
mat k u ecompt thereinto and the Buis for the alleged mmpumL My violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjcm the applicant to a civil Penalty of
nm tome man ftw hundred dollars ($5007.
❑ I.0 owner of the ptvpmy.m my uoploym with aagnss Nes cole eompewthon,
Required Inspections
win da Ilcwaric and tW swnum k notinwnded mortems retook ($C'. )ay. Businw
tc s LiatLse law dna Out l apply an Owner of
and Profnsiom Code: The Comra
Property wW buildaeinprove thermn.and who donsuchwarlahimselfmthmugh his
earemploym, provided oat such imprmemeau are, net intended moRered forsake. U.
however, the Wilding or impnvement is cold within atm year of compleuon. be owea-
Wilder will have de, burden of proving mat W did Out build or improve for purpose of
sale.).
I] 1. as Owner of the property un aaclusively coarsening with licensed unusten b
ConINCI thC projeca (SCC. 7044. Business and Professional GO C:) Tho CorsrYmr] U.
comm raw dm rook apply to are owner of property who Wilds or knprhwn thereon, and
vhacontncu for such ptajem with a counmor(s) licensed pursuant to the Catur n e',
I.icens Law.
nempt unGs See .BAPCImthkasson
Dau
WORKERS COMPENSATION DECLARATION
1 hereby affinn under petWty of perjury arc of the following decimations:
—/
lyt ba eand wnL maintain a Cm iscam of consent mself-i. fm woa ce. carom -
.ties, .provided for by Seed.. 3700 of due Labe Code. for the perfmmmm of the
wort for which at. Permit is trued.
❑ i Ww and will maintain Walters Compensation Insurance, ss tryuird by Seethe
3700 of the labor Code, for the performamc clubs, work for which NU Permit is Wool.
My Wakee. Compensation Insurance carni. and Polity numbs,, am:
Carrier, Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(ITiacoctirn rcsd nat W cmnpletd if the permit is foronc hundred dollen (5100)
or less.)
I certify stat In the pmforman of k for whIs permit is issued. I shall not
employ any Peron in my
NODE TO APPLICANr. 417. after mama u Ceniftuu of Enmptmoil should
Ise,.... ubject 0 the Waster's Compcwtion provisions of me, bor C you mw
M
fawid,comply with such provisions or this permit Nall be dammed mooted.
i CONSTRUCTION LENDING AGENCY
1 hereby afftm an Won is a construction lending agency for the perfamarme of
the wark fa which this Permit is issued (Sec. 3097, Civ. C.)
Lender's Namc
Lender's Address
I cenify Nat I haw, red thus application and new an tic aWw information is
' CO=L I agree an comply with all city and county ordimnm and saw burs Rioting In
building construction, and hereby authoria rePnm stanoes of this city In enter open the
ahm-mendoond pmpeny fm inspection purpenes
(we) agree m saw. i nify and loop hunk. the Cry of Cupenion aeaitm
i Iishiliueajudgmenu. cents Ipemeaw It maym y amus, U..us, cold CityI.
1 APPLICANTeof ths, UNDERM Dsmt LLL C P NON -POINT
/
Issued by: Date -
SOURCE REGULATTO
Re -roofs -
type of Roof
SienwueafAppliean entraMr Dam
HAZARDOUS MATERIALS DISCLOSURE
Win the applicant or fuuue Wilding hmnPantstnmmhandmn ardommatcrial
.
ned by the Cupertino Muntcip l . Chapter 9.13, and the Health and Safety
. season 15532(a)?'
❑Yen
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtainingan inspection, I agree to
Will Nc applicant or forum Willing occupant tax equipment or dcvims which
p _ g remove
emit ha'iummus air contaminates u defied by the Bay Mus Air Quality Management
all new materials for inspection.
District?
❑ Yen
Ihawrewl std ted I ntaundcrChapta6.95oflheCalifor-
7 5 udematW thnifthm Wilding
ruaHmlNhSafny 25505Milmim
dm not curmndY h thatm notify w amumr of dm
rteton, carondriewh h tdouponfimmof t'keremn.
Signature of Applicant Date
r
All roof coverings to be Class '%¢" or better
Owner m auth(5674i age IlkDow