09120121 REV1 CITY OF CUPERTINO BUILDING PERMIT I
v
CONTFACTOR:VANDONZEL
MIT NO:09120121
BUILDING ADDRESS: 10230 LEBANON DR CONST tUCTION
1170 CLARK ST DATE ISSUED:04/15/2010
1ER'S NAME: BARTAS JOHN A AND JENNY L SAN JC SE,CA 95125 PHONE NO:(408)295-9045
OWNER'S PHONE: 4082573414J
COMMERCIAL❑
JOB D ASCRIPTION: RESIDENTIAL
LICENSED CONTRACTOR'S DECLARATION
C ADD FAM ROOM(372SQFT)&ROOF(20SQFT),DOES
���,�,p 1 Lic.4'��`'> INCLUDE
License Clas
Date o STRUCTURAL
Contractor
I hereby affirm that I am licensed under the provisions of Chapter 9 6/11/LO10-REVISION#1 -ROOF FRAME
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's Valuation:$50000
Compensation,as provided for by Section 3700 of the Labor Code,for the Sq.F:Floor Area:
performance of the work for which this permit is issued. r for by
I have and will maintain Worker's Compensation Insurance,asp 4vided Occupancy Type:
Section 3700 of the Labor Code,for the performance of the work fopwl�ioh this
APN Number:34214014.00
permit is issued. T�/
APPLICANT CERTIFICATION PERMIT EXPIRES IF WORK IS NOT STARTED
I certify that I have read this application and state that the above information is
WITHIN 180 A LAST CARL ED INSPECTION.
correct.I agree tISSUANCE OR
o comply with all city and county ordinances and state laws relating 180 DAYS FROM
to building construction,and hereby authorize representatives
(We)agree to aveto r
upon the above mentioned property for inspection pure — /( eld
indemnify and keep harmless the City of Cupertino against consequence
neence of the is Date:
6 6
costs,and expenses which may accrue against said City' q Isst ed b
granting of this permit. Additionally,the,ap
t rstands and will comply
with a1]no source re,IUT4ioris�r ihe, ug rt Municipal Code,Section RE--
9.18. / :�J f.
., �' i +
�,- l� All roofs shall be inspected prior to any roofing material being installed.if a roofis
Datean inspection,I agree to remove all new materials for
ature insi ailed without first obtaining
inspection.
0 OWNER-BUILDER DECLARATION Signature of Applicant:
Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, HAZARDOUS MATERIALS DISCLOSURE
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to undeChapter
I I gave read the hazardous materiag525533r and 25534.9I will of the
construct the project(Sec.7044,Business&Professions Code). C flifornia Health&Safety Code, ections 25505
Chapter 9.12 and the
Health&Safety Code,Section 25532(a)should I store or h )►
azardous
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,
li,;emit hazardous
icbylw
declarations: nt or defic agagement District I
I have and will maintain a Certificate of Consent to self-insure fde Worker s a r contaminants as defined by the Bayld I use AreaaeAiUQu ityC e,cChaent District
and
Compensation,as provided for by Section 3700 of the Labor Co w ill maintain compliance wit a Cup m and
34.
performance of the work for which this permit is issued. provided for by the Health&Safety Code, ection 25 0 5
I have and will maintain Worker's Compensation Insurance,as p Date
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent:
permit is issued.
ance of
1 certify that in the performthe work for which this permit is issued,I shall CONSTRUCTION LENDING AGENCY
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I
ed.
become subject to the Worker's Compensation provisions of the Labor CoYork's for which this permit is issued(Sec.3097,Civ C.)
Code,I must ' hereby affirm that there is a construction lending agency for the performance o
forthwith comply with such provisions or this permit shall be deemed revoked. ,ender's Name
APPLICANT CERTIFICATION
Lender's Address
1 certify that I have read this application and state that the above information is
cnrrect.I agree to comply with all city and county ordinances and state laws relating
ilding construction,and hereby authorize representatives of this city to enter ARCHITECT'S DECLARATION
the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, tans shall be used as public records.
costs,and expenses which may accrue against said City in consequence of the I understand my p
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Date
Signature `ti