05020135 CITY OF CUPERTINO �F'an
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION q
BUILDING ADDRESS: PERMIT NO,5 0 2 0 13 5
OWNER'S NAME: PERMIT LSSUUE DATE
THE HALLMARK
JE: SANITARY N0. CONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMITINFO
�LaBILDOO O PLO l�
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Lop LICENSED CONTRACTOR'S DECLARATION U am i.
C I hemby affirm that I am licensed under provisions Of Chapter 9(commencing Job Desscriphoun
b
with Section 7")of Division 3 of the Business and Professions Code.and my license is `�ry
nin full Tarte and effect. INTER. REMODEL
j�_ Lmeme Chis Lic.N k
Y
n p Dao: Contactor ,S
ZZ ARCHITECTS DECLARATION J
J,K 1 understand my n u es uhlic s
Dllooy
yU //
3 G Licensed Pmfcssionvl
WWN'A- IL D e A ION
Ei Z 1 hemby.Rem Nat I em exempt from the Contractors Cm License Law for the
O O which ire moon.(Section 7031.5,Business and Pmhemoli Code:Any city or county
E:
$ which requires a permit re construct,a@q improve,demolish,or repair any tstractom
ement
prior m its issuance,also mquims the applicant for such permit to rite uigncd summcm — -
nnn
IlutheulicensedpursuanttotheprovisionoftheConuactursLicenselaw(Charter9 Sq. Ft. Floor Area Va ua[ion
¢�$ (commencing with Section70NI)of Division 3 of the Business and Profusions Curio)or
.. that he is exempt themfmm and the basis for the alleged exemption.Any vinladon of
Section 1031.5 by any applicant for a permit subjects the applicant o a civil penalty of 32A671L 0e100 Occupancy Type
not mom Nan five hundred dollars($500).
❑I,as owner ofd"property.or my employe"with will"as their sale compenlation,
will do Ne work end the m-ctum is not intended or nff.¢d(oral.(Sec.1014,Buaio.a.
and Pmmssfoa Code:The Contractor'a Lt..Law doe.not apply m an ewnsa of Required Inspections
Property who builds or improves thereon,and who doessuch workhim olf or through his
Own employe",provided that such impmvem.nu ste not intended oroRered Inflate.If.
however,the building or improvement is sold within one year of completion.the owner-
builder will has the burden of proving that he did not Wild or improve for purpose of
.to I
I,as Owner of the property,am exclusively contracting wit licensed contractors to
co iron thc project(See.7061.Business and Professions Code:)The Commucmr's Li.
ce law it.not apply to an owner of property who builds or improves diamond.and,
who contacts for such projects with a eonoacmr(e)liceaed pursuant as Ne Contactors
License law.
F-1 10 "emit un Se B&P C four t�his(r�(ti�on
IIS,ITI�N DECLARA
Owner�blt�,F�aTSMT Daw TION
1 hemby affirm under penalty of perjury ane of the following decluatimoc
have and will maintain a Certificate"(Consent m self-insum for Worker'sCumpen-
much,a provided Or by Section 3100 of the labor Code,for the perfomtmtce of the .
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,a required by Section
37M of Ne labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Instance carrier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This ucdon need not N completed ifthe permit Is for one hundred dollars($NO
or less.)
I certify Out in the perfmman¢Of the work for which On permit is issued.I dull not
employ any person in any mannerso m in become,subject to Ne Workeri Compensation
Laws Of California.Dao
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compmtlamn provisions of the labor Cnde you most
.J 2 foMwith comply with such provisions or this Permit shall be deemed favored.
z CONSTRUCTION LENDING AGENCY
I hereby affirm Nat then is a convection lending agency for the performance of
!Y 1 the work or which this permit 4 issued(Sec.3091,Co.C.)
{k1
Under',Name
7 z lender's Address,
U C) I certify that 1 have read this"pili"tion and some Out the above in ..hurt is
lL(-' .Orta.1 agme to comply with all city and county ondinsmces and sum laws relating to
O V building construction,and hemby auNome mpmxnutixes Of Nis city to enter upon the
above-mentioned property for inspection pis, m..
t1 (We,).,me to ave,indecent fy and keep harmless the City o(Cupcionn against
V Z Habitittes,judgmentns
s.costs and expenses which may in any way accmc against said City
n consequence Or Ne granting of this Permit.
" APPLICANT UNDERSTANDSSS,,r///���ND WILL COMPLY ALL/�N'ON-POINT Issued by: Date
SOURCE REGUI-ATIONS. {�yt[NALr/n/Isgr •ys Qs O
Qll//UAIf-/fY/l +lr Re-roofs
Signature of ApplicanVCmtrscour Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant err future Wilding occupant nom or haMle hmardou,material
a defined by the Cupenin0 M��t411�ttssqqqicipal Code.Chapter 9.13,and the Health add Safety
Code.Dye. 533(")? \/No All roofs shall be inspected prior to any roofing material being installed.
1� Will the applicant/of futtt c building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.t hacamons air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
mrkt?
❑Y"
I have mad the hazardous aerials requirements under Chapter 6.95oftheCalifm-
nia Health&Safety Cadc,Sections 355D5,35533 and 25531.1 undcrsmtM that if the building
dots not cunenif ha a tenant.that it u my resp9nsihili y m notify the occupant or us,
rtymremcatswninn t rgOgogn� i . n�cupgopy.0. Signature of Applicant Date
Owncrorautho dace L1�Upam All roof coverings to be Class "B"or better
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