05080086 CITY OF CUPERTINO r a't #+ ysw Jri+a Y' '�' '
BUILDING DIVISIONPERMIT rCONTRAMORiINFORMATIgN:
r;•Y„i). ..>ti'.a.. r":�+ .�, t' ,1, b t1�".4 ,if1Ps
BUILDING ADDRESS: KATHY LYNAM-ROHRS PERMIT NO.05080086
10520 DAVISON AV
OWNER'S NAME: PERMIT ISSUE DATE
KATHY LYNAM-ROHRS 2005
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
30 j LICENSED CONTRACTOR'S DECLARATION Job Description
u 1 hereby&film that 1 am licamed umkr provisions of Chapter 9(commencing
with Smtkm If fl11)of Division 3 of the Business and Professions Code.m l my limmat hs
+� I.full form and eOWL
y�z LI"ns,tins& ��NADD 639 ' (2ND FL- EDr�LRM/1 BATH)
Dam Conuaclar REMODEL 1001
' B
ARCHITECTS DECLARATION
elw
I undnd my plans mall he used a public mcoMs
t�
Licensed Pmfas&ional ��� 6�
OWNER-BUILDER mDECLARATION /
.� I 1 hereby from that 11. exempt from dr GanonsCo Licence Law for the (� o
O O which ex mason.permit
t 7011.5,m itwor.and rmfessions h,.1 Any city her county
S$� which roquires&penis to mnaumL alter.vnpmw.Mmnl"ub,or mPelr any swctom Eks
a PHe,In its issuance,also requires the applleanl for such emil 0 Ne a signed statement
Net M h licenced pursuant an the Provisions of NO Contractor's UcO.Law(CMpmr9 Sq.Ft. Floor ArIING Valuation
F $ (mmmcnetng with Soctian 7000)of Division 3 of the Budnnsmd Profcuinns Code)or $145985
that he is exempt themfmm and Nb
e ah for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more dun Bw hundred dollar,(SSW).
0 i,u ownes of Ne property,m my=Pluyoes with wages a dteir ah eompenution,
will do the wah.and the&wmum Is not Intended oraffcred forsake(Sm.7011,Business Required Inspections
and Prefossians Code:The Conerector's Limm,Low don not apply to sn owner of q P
property who Wilds or tmprows thereon,and who does,such work Mmst If or through his
ownemployms,pmvided that such improwmenu am not intended moaered foruk.If.
however,the building her Improvement is mid within one Peter of complehon,the owner.
builder will have the burden of proving that a did ant Wild her Improw for purpose of
um.).
h
Is Owner of the property,&m allusively commuting with licensed contractors to
Imet the projem(Sec.7044,Business and Professions Cade:)The Contrum's U-
ecnse law dma not apply to an owner of property who Wild,or impmw,themon.and
who contracts for such projects with&contractor(&)Iicenad pursuant to the Commerce,
Lmense law.
Ola em under,cc, B&PPC�for this We
Own r Dam9,y(,5 As
iRK 'S COMPENSATION DECLARATION
Ihemby x07 under penalty or perjory arc of rite(ollawing dulanuons:
low and will mdn Wn a Cedrnam o(Conanl to alb Wum far Workefs Compen.
cation,u provided for by Section 37M of the labor Code,fm the performance of the
work for which this permit is issued.
0 1 have and will mdnWn Worker's Compensation Insurmm,as Inquired by Section
3700 of the law Code,for the perfam u a of Ne work fm which this permit is issued.
My Worker's Cornpematlon Inunnce carrier and Paltry number me:
Carder. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSA71ON INSURANCE
(This smum need not becompleted If the permit is farms hundred dellen($IOB
lir toss.)
1 certify that in we performance of the work for which this perch Is issued,I mall out
employ any person in any mm 1 1mbjecuoM Workcn'Compenudon
laveoft-{'(ot��W .Ip•l—"Al
Applicant c-a PLI Mrf. a($
NOTICE TO APPG If,Commaking this Ccntnam W Exemption,you should
become subject y the Worker's
provisions Or win omiidon&of the lad Cade,you most
.,O foMwith comply with such provisions lir Nis permiuhdl W deemed rewkW.
r3 CONSTRUCTION LENDING AGENCY
[-+ I hembyanor Nal Nem is mmrmthm lendingapency lot the unfamance of
lYi> the work for which this permit Is Issued(Sm.3097,Civ.C.)
�~n. Lentims Nam: ,
z Lenders Address
U O I mutify that I naw rad this application sad glass d a the aWue Information I,
Iy;^ mmn.l agree 0 comply with all city and county Ordinances and tote lam misting to
w
O rV^ Wilding consction,and hereby aumwa armcmprommutiof Nis city to enter upon the
W &bow-menuomod Property fm mspmima pw p ewL
D, (We)agme to saw.Indemnify and keep harmless the City of Cupertino against
to liabilities,judgments.costs and expenses which may in my way accrue against said City
U Z in comequcue of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S R E CUL ONg, linpp -- _
RIIN/d Mb-'7 Re-roofs
Slgnawro of ApigmaniUmmucicar Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will to applicant or future Wilding occupant nom or handle aardom material
,s Maud by the Cupenlnn Municipal Cade,Chapter 9.13,and the Health and Safety
Cade.section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
[D Yes ANo
Will the applmam her fumm Wilding Occupant us,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
. harardnus at'mnuminants as Mnned by Ins Bay Area Air Qudily Management all new materials for inspection.
Disuiu7
❑Yen ')QNu
III mad Ne haadwsmamdalsm9uimmcw under Clupter6.95 oftheCelifor-
ni,HeshhASafmy COM,S.6.25305,23533and25534.1unMnuMth ifdss Wilding '
does not cumnlly haw a imenu that It m my reepansiblllty to notify to ottupat of the
uquimmenlawhichmWmelprimto of.Ccnl0casofOcmputey. Signature of Applicant Date
rias t l p,te All roof coverings to be Class"B"or better
Owner or