05040037 CITY OF CUPERTINO ,y.� - -+ xss�a, fms- 4'
BUILDING DIVISION PERMIT 9 O
NTRACTORANFORMATION
BUILDING ADDRESS: PERMITNO.
05040037
1506 N RGGTHiLL BLVD
OWNER'S NAME: PERMIT ISSUE DATE
E HALLMARK GROUP
SANITARY ROL NO.
ARCHMC YENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Lop
LICENSED CONTRACTOR'S DECLARATION Job Description
UC 1 heathy affirm that I am licensed under provisions of Chapter 9(commencing
t!
with Section]1711U)ofoivision 3 or Ne Business and Professions Cote.and my license is
�zF Licreeandertat.
cmmGlass Lle.• INTERIOR REMODEL/BATHROOM/CLOSE
Dam
j}�?
F a¢ contractor
PS DECLARATION
� 1 understand my plans shall W used M public records
�yU /
3 a G Licensed Pmfcssirnel
3 OWNER-BUILDER DECLARATION
x1 bemhy am that 1xem
epts i and site Contriver,Licenlaw for the V
O a fO
following main.(Sccdun]PAL1.S,Business Profcssium Code:Any city or county O�
K m which requires a Permit to continues,alar,improve,demolish,or repair any structure
m—sn prior in its issuance,also requires the applicant for such petmilto file a signedstatement
that he is licensed pursuant teethe previsions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Va era ton
mi-c' (commencing with Section 7")of Division 3 of the B usiness and Professions Code)or
a, $ that he is eaemps thmerrpm and the basis for the alleged exmption.Any violation of
Section 7031.5 by any applicant for a permit subjects Yoe applicant to a civil penalty Of 3 perp p Occupancy Type
not more Nan Gins hundred dollen(55007.
C I.as owner ofthe property or my employees with wages as Heir sole compensation,
will do Ne work,and the structure is not untouched oroffemd fofsale(Sec.7064.Business
and Profearm.Cade:The Commerce,License Law docs not apply to a ow.,of Required Inspections
pmpeny who builds or improves thereon,and who does such work himseu or through his
Own employees,provided that such impr mmaa am not intended oroRemel for We.If.
however,the Wilding or improamml is aid within one year m(completion,the owner-
builder will have dre burden of proving Nat he did not Wild or improve for purpose of
salt.).
C 1,as owner of Ne property,am exclusively concocting with licensed contractors to
construct the pmject(Sec.7064,Business and Professions Code:)The Contractor's Li.
aux Law docs not apply to an owner of property who Wilds or impmvM thereon,and.
who cares for such projecs with a contractor(s)liuved pursuant m the Cantnctoes
License law.
C I am e.empt under/�S$,�{/f� B Ar
Owner R MOO I99— — Data
R ER'S COMPENSATION ECLARATION
1 hemby affirm under penalty of perjury one of the following dechralimucc
rc and will maintain a Cenifcam of Consent m self-insure for Wo ime,Compen-
nm
as provided far by Section 37M of dm labor Code,for the p f....of Ne
work for which this permit is issued.
C 1 have and will maintain Worker's Compensation Insurance,M required by section ,
7]00 of the Labor Code.for the performance of Ne work forwhich this permit is issued.
My Warkces Cmmpematiom Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TTIs section need not be completed lithe permit is foronc hundred dNlan(SIM)
or lead)
I certify Nm in Ne perform 'c of Ne work for which Nis fiction is issued.1 shall of
employ any"eram in an o e nt a 'on
Laws of California.D
Applicmt
NOTCETO APPLICANT: L after maks is Ccnificate of Exemption,you should
become abject in the Workers Compvmetion provisions of dtc labor Code,you most
.,z' fordwith comply with such provisions of Nis peon it shall be deemed nvokcd.
z Q CONSTRUCTION LENDING AGENCY
[r l hereby affirm Nat there is a construction lending agency for the Performance of
r1,> the work fur which Nis permit is issued(Sec.3097.CO.C.)
Lender's Name
=z Lender's Address
U Q 1 certify Nat 1 Issue tend this application and suite that the abm c information IS
W F mtmet.I agree m comply wit all city and county on inameas and sure laws misting to
0 Wilding construction,and hereby authorin mpnscntatiues of this city to enter upon the
W ahove-mentioned property for inspection Purposes
(We)agreeave,to sindemnify and keep homiest the City of Cupenim against
C.
liabilities,judgment,costs and expersca which may in any way see=against Mid City
U z in consequence of the granting of this permit.
APPLICANT UNO RSTANDS AND WILL COMPLY WITH ALL NON-PIssued by:9 Date
SOURCE REOU . iJ
Re-roofs
Signorinur r m/ mtrmum /`�$�l ref �Da/mYJ
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
will Ne applicant or future building Occupant store or handle havallous material
as defined by the Cupertino Municipal Cade.Chapter 9.12.and the Hca1N and Safety
Code. Dyes 25572(,)? All roofs shall be inspected prior to any roofing material being installed.
❑Ycr Nu
Will
the applicam or wee building occupant
vu cyuipmem or Jcvices whicM1 If a roof is installed without first obtaining an inspection,I agree to remove
ita zmmus air contamm s as JCMcd by the Bay Area Air Quality Management all new materials for inspection.
Well
C Yes
I deme mat!the bavandmiumaterials nquimmcns under Chapter 6.95 of the Califor-
niaHealth k Saray Codc,Sceums SN15,25533 ad 25534.1 undcrsund Our if the Wilding
does not currently hove a truant,Not it is my respmrshilby in nuts I the sxeupant Of the
requirements wit rt t%��^�(um�j/$s�}ma�n roe cc atemftxP7. ,/ Signature of Applicant Date
Owner our amt roma gm/���� "' 1 p Dam All roof coverings to be Class,.B,,or better
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