02040128 CITY OF CUPERTINO COIITRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO
21860 ALCAZAR AVE WILLIAM HURT 02040128
OWNER NAME APPLICATION SUB DATE
WILLIAM HURT 04/23/2002
PHONE SANITARY NO. CONTROL NO
C�ARCHITECT/ENGINEER BUILDING PERMIT hYfO
µ, BLDG ELECT PLUMB MECH
i LICENSED CONTRACTOR S DECLARATION Job Description
'�y I ,7,yXd.fDnisim3.ffhrB�ntler provtsmnsof Chapter indallenemg TEMP POWER POOL
witn b1cChs and efniviaion3armeH aana r'rate.+,onx Bade.ana,ny hoen�e
alt L Po Duck and effect
:O z u Ucen Class e
OyU Um• SDFC_t Clarbarefor
33 u,� � A HIT T'S DE N
i I understand my Is It, a�a n m records
j p C Licensed Professional f/��
.sae o
OWNER-BUILDER DECLARATION
I hereby ifrso that I am exempt from the Coalmen-l"L oemc Law for the
following reason (Section 7031.5.Busmess and Pmfessmm Code Any edy or loamy $500
F ee wli
0.0 3 poo,to lu our air n npe.ra[.mu o reto gn mrtswthce t a palp¢hre,a tm m pfar vsuch d elcmnonhsnn,o oBc lercaPmsigr nand
statement
t(hcaot m hmecrs n nl,cneg n¢wdM p u5 n«uiraom n t9d 0 t1h10e)p orof vDsmmnsis o on f 3 t hoe f C,hoc n wBocsminrc's s s L aicned Pe r ow s ohpo I
e„!3§g fh.E ,g Valuation lss(CnCr9
or that he is exempt duiefroin and the basis for the alleged wmad,t on Any violation
of Benton 9031.5 by any appbcam fill.peen,n tubreen he apphwnno a et”?pea.my 10�PN 1�Ij @ Occupancy Type
.of not more than Bali hundred dollars 115001 l '
El I-,as owner of the property,or my employees with wages res their sole compensation, Ana - 17 hTTf,17 t7T.Ff'Tl?T 171 T.
will Jo the work,and the Intents,s not m,eaded or offered for sale iSm:90.1A, Required Inspections
Bodam,s and odessmns Code,The Contractor's License Law does not apply to an q P
0
caner of property Who budds cr,mprom,thereon,and who d«s such work himself
_or through his own employees provided that such cament menu arc not intended
lse-ye r or
offend for sale lf;owner-lan r,the building or burden of pro n said within not year of •.
completion,Prove for the arse of will have the harden of proving that he did not build or
,mpmvc for pumou o!sale) '
1L as ow+rm of the paopeny,am eaclucivdY consmamg wish hcenaed examwors,o ;_
cools tua the pro)ect(Sec 701 Basins and Proreamns Code)The Connarfin I tl�+® ,. , ��
1-wen a Law d«s not apply to as owner of property who builds or notaries thereon, G
and who contracts for such PrAern with a coanacmr(s)hco,ud Pursuant to he
_. ... ._..-_ _______
- Comrea rrs Li use Law. I, -
❑lemexc t derS<c' t8&�jt�� APR 2. 9 2002
% Owner TI N
WORKER'1 COMPEN IONU CLARATION
1 hereby af&m umle,penallY of perjury one of the following decVamUOas 13UILDING
_1 0 1 have and will'maintain a Cenificam of Conant to self-insure for Worker's -
. ,Compensation,as provided for by Section 3900 of the Labor Code, for the
performance of the work for which data perms Is issued.
❑1 have and wdl mamum Worker's Compensation Insurance,as rcgmred by Section
31M of the Labor Code,for the performance of the work'fer which this permit is
cr and Policy numhr are
macs My Workers Compensstion Insurance cam -
Gamer,.:•,i: Ni"•Pohl,No ,_ �w. �;._...•-,w ._ .. ,r .
CERTIFICATION OF EXEMPTION FROM WORKERS'! 1_t ,•.'( li,l1% �.a
o._.. ........_... COMPENSATION INSURANCE. . _.-.___ -.__ _.,___.._._.—_._.___.,..___ .___..
" -'f ln,;lemon needno,he complemd if the permit is for one hundred dollars
(1100)or less)
APP If,miser e hs
rat - - .. :. -
n Laws Cahfomi for wh)ch ube r,1.the Works,I
16emfy Ghat in the pct5oniiance of the work „
'hall not employ any,coon,n a n �mbl«t m Pte Workers'
ET �— ,er�iBcamof Excmpnuor You should
become subiecno die Worker's Compensation provisions of the Lab it Code,you most
Q O forthwith comply with such pmnaons or this 1-11 shall W deemed resumal
Z _
CONSTRUCTION LENDING AGENCY
_ 1 hereby affirm that them is a construction lending agency for the performance
of the work for which tors pevml b oared iSec.3099.Cis.C.) -
0 Lenders Name.. ..._. .. i-. _ .. .. . .. ... ... .. ..
z LendasAddus'
U 1 cagily that 1 have rued NW city and and stair tn the above information is
to Wilding 1 agree m comply with all my and county representatives ordinances and state laws enter upon
Q U mw-met aired randy, or impedmin rcpresenmuves of this cnymenmr upon
A. the eboWr)igmned property far inspection purposes
hair ,
.Fi y ,Wc)agree to sake,indemnify and keep harmless the City of ,ma ag i st said
Vl I,abJd¢s,)udgmcnts,coNor expenus wM1mh may m any way accrve again said n �q `/ly�l(,•/]t/
(,7.� City m conse9ucnce oft tiag D th,s pecmn. 1
_ APPIJCA UNDER AND N' LY WITH'ALL NO POINT vl'SSUed by: ®1 t /VJ �A✓/ Dale
/�OIIR/J(r1^�F1 UiL(AT/I�(, '" "" a'21s� ,
6,gnaNfc^ofA - .' " � me Re-roofs
m ,er912 and.HAZARDOUS MATERIAL handle` uNous matuial - ,Type Of ROOF.... - - - - -- -
5 DISCLOSURE
Roof—
as defined by the Cu moo Mumapal Cade,CT nd the Health and Safely -
Code,Scc,lmv 2553201)or future build,n acre 't store or h i r x A
PP g Wit
pe P
❑Yes... 1, �NO r e
_ -.- All roofs shall be inspected prior to-any_rwfing material being installed.
wdl tna gppbkamm mmre ba,la,ag«mpan�aae eaa,pmk�t or ae�ie�..an,kn If a roof is installed'without first obtaining an inspection;'I agri remove
limn haaiidous mr comaminams u defined by the Bey Area Art Quabty Management
D,ana9 r, t all new materials for inspection. Applicant understands and will comply with
Dues, ,; l�No all non-point source regulations. „
` I have read the haaar,lnes materials notp reni under Chapter 695 of the
California HcaWih Safety Cede.Scamns 8505.25533 and 25534.1 undcrsunl,hat if the budding does ism anon ndy have a mmnt.that it s my resprensihdn,m inofy,he
occupant of the rcgrue u which must x met prior to issuance of a Cemfeem of
G«upa« \ 9 ---Signature of Applicant Date
�((' A A �Y��
�f sraul6��e�gCtA— - ,. Date All roof coverings to be Class `B"or better
OFFICE