08070102 CITY OF CUPERTINO
BUILDING DIVISION PER -ON'T"CTORimORMATION
BUILDING ADDRESS: PERMITNO.
10441 PHAR LAP DR GARDNER CONSTRUCTION CO 08070102
OWNER'S NAME: PERMIT ISSUE DATE
ARTHUR AND MARIA LECLAIRE 750 LOCUST ST 07/24/2008
ONE: SANITARY NO. CONTROL NO.
(408) 615-8010
ARCHTTECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT FLUME MECH
X00 LICENSED CONTRACTOR'S DECLARATION O O O O
1 M1wby.loan Nat I w li¢nad aMcr pmvianns of Clumpter 9(commmcmt Job Description
w)N Sad.nl").f Divism.3ofthelbruwasmd Professiam COM,aMmy[I...I. REVISION—REMODEL NEW HEADER REPLACEMENT/FOOTING@
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T'Sr DECLARATION RQN`�G t]LrsT /p
Q ARCHf1EC15ublicm ORIG#08040232
a� 1 undewnJ my plans Nall he umtl u public rerords
JyU
yLLa Licensed Pmfessi.nal
5 OWNER-BUILDER m Ce CommaON
coo hereby afsw that 1 em xempt from the C.nI..ors L ten a law for the
coo O following mason(section
aavasr susintas and Pm.loom Cade:My rily s county
which requims•permit re ewswtt.Iter,impmw,h pamh t a repoir any ammum
_Zy prisms accun¢,arurequiw theapplicantfor sucCommute Lics.Jib!A Law sutwem
E�G thuheulieenmd Secdntm Nepma,kv rfdc Comramra d itrlaw(Cb )., Sq.Ft. Floor Area Valuation
$ (cwmeis mum
t therefrom n d)the basis f r of the Buanwand on.Anyou Caee)or $2500
.. Net he is ue5Pl therefrom sntl the aper for bj ds�ho asuman to Any l pawn of
Section.1.. than fins
but applrcmt for a permit mbjau thte Applicant m a coil putalty of Number Occupancy Type
notm.mNanrlwhaMmdaoll,n(S50pk 32635042 . p �' YP
❑I.uowser of Ne pmlamsY,amy wploym with wagnuthteir mk ewpevadon,
will dodmsions Ca Ne Too
Casouts Liamm Law
a.k(sec.In an Basions
W aty who
Cale:The Crnc.cmfs nd whe law data oat apply m rt roux.offis _ Required Inspections
pwpem who builds orImpmvu b imp,end whodoesmem wank M1 rmforarNmum his
own wPloycpe.proNded Natsahimprowmmain ant earofmrroRwtl the ale IL
bultdo,.Neavoth twimpmtemung Oat mdidnmu)ear of cmtpkdonr polum of .
builder HR love We buNan of proving Nat M1e did not Wild a impsme for purpose of
sale.).
❑I.u causer or the properly w reclusively conuactint with 0seued ranbamn W
c.mtm t the Mjcm(Sec.TOm.Business and Pmfasiou Co kc)The Crntm mrs W-
mnm raw does rot apply in.n.wnes of Impact who build,.,rmpmws thereon,and
who contracts for such Micas with a contractor(s)focused pursuant on Ne C.ntramors
Lice.law.
O l um exempt anchor See .B&P C for this repeon
se Can
WORKER'S COMPENSATION DECLARATION
1 hcmby.T.under pewt'of perjury ane of ex frlmwas dala o mm:
❑I law aM will for by
•CmuficW.f Copecm r Cods.for n, Woa...f On
wilt,u provided for by Ssis u dToO rf Ik labor Cove,for Ne perfowan¢rf thu
wart(a whiem this prank r issued.
❑1 have and will maintain Warterr Compcnsati.n Imurance,as rugmral by Secv.n .
37W.f the labor Code.for On performanre of Ne work for which Nr permit is issued.
My Work-a s C2wWramx ompedoo ucarer and Policy ntumbbeerr/am:
r
Caer 56 '7, %A!. Poliry Na.�3 1 &���
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tau mmwar reed not becwpleud If the permitis(mom hundmddollan(tido)
or less)
1«rdfy Net ld Ibe performaae of the wort far which Its permit u Issued,l shall nm
employ any perm.in my manse,an as to become subject to Ne Workri Cwpcuadon
Laws of California Dam
Applicant
NOTICE TO APPLICANT:IL after maid,this CeniBeam of Exemption,you should
become subject on Ne Worker's Compensation pmvraru of the labor Code,you mute
.J O fo thwid,comply with such provisions or Nu pmmit shall is,dsemed revoked.
'Z
CONSTRUCTION LENDING AGENCY
F+r 1 hereby afDrm that cure u a mwration lemilr a for do
t 6^n' pmfuwutm of
Ci Le work far which ads pewit is issseseC)
d(S .709T,Civ.
Ia
�W nticName .
.7 z !.coders es Mmss
e
U O 1 m'rfY Nat I have read Nis.pplkaumr and arm d u am mum iNmm.don r
^, rnwa 1 agree m comply with aea all city and county andinsand sum laws relating m
O il'J buildingamorn,cdon.and hemby mthouim mprnnulws of Nu city N enkrupon Oc
W .hove-mat mad plapeny for impec4M purp mae
a (Wc) C.Ir mw,indemnify and keep hawlns dx City of Cupernr ag.imt
h liabilities,judgments,torts and espertsca which may in any way arra gent mid City
U Z AcPLICANT of the UNDERSTANDS AND
pewit /1 is ••y _
^
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SO Date
YR REGULAT�pS.
Re-roofs
Sigwum py ppli aConuaiur . Dau
HAZARDOUS'MATERIALS DISCLOSURE Type of Roof
Will thx applinnt m forum Wildint aavpantmcc m NnEle hrurdou maurY
ss ceased m 25 32(.)? Munici WI Cotle,mapper 9.12 and ex HNN antl Safety
cade.s«d.nsssn:r,)+
❑Yes ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant m futum Wilding oavp on pea equipment a eruts which If a roof is,installed without first obtaining an inspection,I agree to remove
arkh�gnu air contaminants u dalncd by the Bay A.Air Quality Mwagcmcm all new materials for inspection.
DistricDYn pNu
I haw read Ne hasndoua nommods requirements under Chapter 6.95 of thx c lif n-
nuHeslth&Safety Code,Sccaope 25505,25533 av125534.1 undcmvW tha ifthc buildint
dura ,cuwndy how.¢nam,that It r my rupownwhy m wary On ocvamm,or the
�yI nuwhkhMUSL ro ppt,i�oorwisss�cooraccrtificauoloccPpY
/° ` 0 � /zy/O q Signature of Applicant Date
-7C
Owne aramboriagent Tran All roof coverings to be Class';.a'or better