05030020 CITY OF CUPERTINO �•�.�, .�-ro>�= x '� "�'^"•' '"'
BUILDING DIVISION PERMIT -;CONTRAgORANFO,�R�MATION
BUIIDDIG ADDRESS: J D HAALAND CONSTRUCTION I1 LIMIT NO.05030020
OWNER'S NAME: PERMIT ISSUE DATE
HENRY LO 19305PT,
g: SANITARY NO. CONTROL NO.
(831) 726-1577
ARCHITEC MNGINEER: BUILDING PERMIT INFO
BLDG EO PLO O
jOp LICENSED CONTRACTOR'S DECLARATION JobDescrition
I hereby affirm that 1 am licensed under pW
mvons of Chapter 9(commencing P
with Section 7000)ofDivislon 3 of the Business and PmAessions Cade.and my licenm is
w In full force and effect. SFDWL-2 STORY (3598 ! -LIV.)
?�? Lieenm ClanLie.N
Dam Cornracr GARAGE 624 '
ARCNI'IEmCTS DECLARATION
I understand my plans shall W used as public record$
ant Licensed Professional
`„ OWNER-BUILDER mDECLARATION
za E I hereby.(Sere on I I.S.exempt from the Contractors o e:my c Law for the
p O which re recon.Permit
to]1131. Business and Profession Cade:My city m county
tere
3$tci which is issuance.
a permit re ennpmct,aper,hnpmve.demolish,or repair ed Rromure
x pdarmiuiumnmdsuantlso onqustM apional rl othe a ch ontracmitmgensle ae Lacdsuumcm
o
that
ommenceeing withSectionToNIofDivionsoftheCousines'alJeens.hawsCook)9 Sq. Ft. Floor Area Val Igi�15498
that he o mom it ducreircon d the
Division]of LaceBusiness
cos and Norneflon.Any
lagan or
Nat be V eumpt therefrom sod d¢bub Ise me alleged eaempdan.Any vial&tiun of
Section 7071.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
out mart dun five hundred dollen($50(y). 37507055 . 00
❑I,uheworof dal pml�]y, re I, uintendedwiresea{eaorthepsol.7W,Business will do thewoh,mal the he Commear's intended Lawddmruk(Sey 0 an owner
Required Inspections
and Pro who buildsorimpaterves
Cade:The Coneacmr.Licensendwho law urea ret apply m an oweer is q P
property who buildsofimprot suthereon.andwhodoessuch work Groff for through pts
own employees,providedoriNn such improvemrntsare not sear ofo or lettoA for rale.if.
however,amWildingsh8ordes of pmenthcoldwithin can year of temple,for
me ore of
Wilder wi0 hate dm berden of proving that be did not build or Mprove far purpose of
ule).
❑1,as owner of the property am co clwively contracting with licensed contractors to
cowtmn the project(See.7044,Business and Pmfusalom Code)The Contractors Li.
ansa law does not apply m an owner of property who Wit&or improves darner.and,
who convammu wn""acm with acomncrorp)ileensed punuemm the Contractor's
License Law.
01 am eaemt oder Sec. .B&PC rthi& anon
Owner Data
ORK S PENSATION DECLARATION
1 hereby affirm u penally of perjury one of the following declaadom:
❑I have and will mainW n aCeNficem of Consent to self-buure far Woftes Comp m.
sation,u provided for by Section 7700 of the labor Code.for the performance of the
work for which Nis permit is Wind.
❑1 have and will maintain Workers Compensation Issuance,as required by Section
3700 of the Labor Code,for the performance of dor work for which this permit is Issued,
My Workers CompenWan Insurance ca rler and Policy number am:
Canler: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibiametion neW nwbecomplemd MW permit is foroeehundreddeners(7100)
or ma.)
1 unify that in the performance f tiro work for which this permit is sound.I shall not
employ any person in any man sou m beambjectsotbe Werke Compensation
Laws of Callfami
Applicant
NOTICE TO APPLICANT:I,a r mak is CertlOcem of Ex Lion, Id
become subject ro the Worker's Comite t an provisions of the Iah Cade you must
0 z forthwith comply with auch pmWWon o is permit shall he deemed revoked.
z O CONSTRUCTION LENDING AGENCY
(.r (hereby M.The,dem p a construction lending agency for the performsorn of
C the work for which this permit a intend(Sec 3097,Civ.C.)
G0 Undoes Name
z, lander.Address -
U 0 1 certify,that I have read this application and sum Nn f above information U
U.F corrin I agree to comply with all city and county oNinomea and sum law&mining m
0 U building construction,end hereby authorize mpreacnutiwa of this city to enter upon the
Liz
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
,A liabilities,judgments.costs and eaparns which may In any way accrue against aid City
(„) in consequence o the granting of this permit.
APPLICANT DERSfANDS AND WILL COMPLY WITH Aq NON-POINT Issued by: Date
S TIONS.
�C Re-roofs
Signature
e H i. mUSMATERIALSDISCLOSURE
D Type of Roof
WOlthcapPli future building occupantaose or handle hacardam mamrlal
u dented by the Cu as Municipal Code.Chapter 9.12.and tiro Health and Safety
Cod.,Sanson 25532(a 7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea ON.
WIII the applicant or future building occupant use equipment or devices which If a roof IS installed without firs[obtaining an inspection,I agree to remove
jnb.
rurdnw air comoninanu u de0ncd by the Bay Arta Air Quality Management all new materials for inspection.
ict7
❑Yes ❑Nu
I have mad dsehaerdsusmamrfatsmquirements underChapmr5.95 oftha CWifor.
,uH.1 &SafmyCadc '$tions 25505.25533 wW25534.1 undameral duifdn building
does not cumumly hate tartan the p iffay reasouiMlity m mtifY meupant of the
requimmcn t emaprioJ suanccotacatificRu Signature of Applicant Date
Owncrur wtharircd gca t p All roof coverings to be Class"B"or better
(%