03100044 CITY OF CUPERTINO �
BUILDING DIVISION PERMIT CONTRACTOWINFORMATION ?
� , � q� -
BUILDINGADDRESS: FRAN LEE CONSTRUCTION INC PERMITNO.03100044
F.R'S NAME: 10935 MIRAMONTE RD PERMFFISSUEDATE
-42
E: (408) 996-2527 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEBR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MP.CH
0 0 0 0
00 LICENSED CONTRACTOR'S DECLARATION
Ice 1 hereby affirm mm I am licensed under provisions of Chapter 9(commencing Job Description I p���®
0E with sects ]OBIp Of Oivision3 of the Busineca ayd Professions Cnde,and mylicens ix ��!
In full G and effect ✓
;�= seen lore I� Lien 3 DEMOLITION OF HOUSE
D oEDEOCT 2 0 2003
CIIITEI'S CCLA ION
`d< ✓I undcrsland my plans shall M used as public records
:4u
o< Linpt dProfessional BUILDING
OWNER-BUILDER DECLARATION
aP I hereby affmm tbm I am exempt from the Contractor's License Lew for Inc
.ctO following man n.(Section 7031.5,Business and Professions Curb:Any city or county
m which requires it permit to ematerel,alta,improve,demolish,m"Imo,any structure
res
Za poor In its iuuance.also mquithc applicant I.,such permiuu flcaaigned etatemem
that he is licensed pursuant ha the provisions of the COnoactods License law(Chapter 9 Sq. Ft. Floor Area Valuation
:FO (commencing with Section 7")of Division 3 ofmc Business and Professions Cook)or
that he is exempt therefrom and be basis for me alleged exemption.Any violation of 35918015 . 00
Section 0031.5 by any applicant for a permit subjceB the applicant to a civil penally of APN Number Occupancy Type
not more man five hundred dollars(5500). P Y YP
0 I,as owner Orme pmpeny,or my employees with wages as their sole compcnsation,
will do be work and the swctum is not intended or offered for sale(Sec.]B14,Business 704 _
and Professions Code:The Contractor's License Law docs not apply to an owner of M Required Inspections
property who builds or improves thoomm,and who doessuch work himself or through his
own employ=,pmvith d that such improvements are not immuded maimed for sale.IL
however,the building or impornmenl is sold within one year of completion,be comer-
builder will have the bnrdca of proving that he did not build or improve for purpose of
ole.).
0 1,as owner of be pmpeny,ion exclusively contracting with licensed contractus to
construct the project(Sec.]floe,Business and Professions Code:)The Contractor i Li- .
corse raw does not apply to an owner of property who Wilds of improves themun,and
who contracts for such projects with a eo mehor(s)licensed pursuant to We Contractor's
License Law.
0 l un exempt under Sec. ,B&PC for this mann
Data
WORKER'S COMPENSATION DECLARATION
01
1 hereby aRirm under penalty of perjury One of the following declarations:
haw and will maintain a Cenificam of Consent to salt insum forworker'sCompen-
I
sation,,as provided for by Section 37W of the Labor Cod,for the performance of the
work for which oris permit is issued.
0 1 ban and will maintain Worker's Compensation Insurance,as required by Scelion
37M of be Labor Code,for the performanee of be wort for which this permit is issued.
WarkcriC nsation Ins carts and Policy numbtaice
m Policy RA a U
-ERTIFICATEOF Pr1
M0N FROM WORK R
COMPENSATION INSURANCE
(ThBseetioa need not W completed if the permit is farone hundred dollars($100)
or It
1 certify War in the performance of the work for which this permit is issued.1 shall not
ampioy any pc.a many manner so as to Wco rm subject to the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenificale of Exemption.you should
become subject to the Workers Compensation provisions.(,he Labor Code,you most
z forthwith comply with such provisions or this Permit shall be deemed invoked.
ZN CONSTRUCTION LENDING AGENCY
1 hereby affirm that Were is a cmntruction lending agency for the performance of
11 the work for which oris permit is issued(Sec.3097,Civ.C.)
A A Lender's Name
5z Lender's Address
:)P 1 sentry the w re
1 have this application and sou above We Sinformation is
y E-' corm.I agree m comply with all city and county ordinances and slate lawswsM12¢rating to
e
�U buwc-mennswctiunand hodbforth aumome«mms, tiro of this city menter upon me
above-(We)anedgre 1.sov,forianhy and keep
Y y (We)agree m save,indemnify and kith harmless the City ra Cupertino idCtgains(
r % incises.s.consequence
Of the costs gaming Of thisexpenses c which they in any way acemc against said City
;J z APPLICANT,UNDERSTANDS
Of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITMI L NON-POINT Issued by: Date
SOUR?R4NS.
Re-roofs
si rear Appue JC traemr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will cant or future building Occupant store or handle hazardous material
as defined b me Cupeninn Municipal Cade.Chapter 9.11,and the Health and Safely
_Ajjfte.Section 155350)? All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building arupont use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
it M1a'emdnus air cnnmminanB at Jcfncd by the Bay Area Air Quality Management all new materials for inspection.
soviet?
DYcs LONu
1 have mail We hmaNnus m ncrials mquimmmis under Chapter 6.95 of the Califor-
nia Health&Safety Code,sections 159)5.35533 and 25534.1 understand Wet if the Wilding
does not curemeant,mat it is my responsibility ,,trimlytrimlypa
y the occunt nl We
require Bob,; m.aIlk otipmomissmance.faCcinKiiiiddafoclop, exo Signature ofApplicant Date
(u
Owner or iacLagen, D All roof coverings to be Class "B" or better _