05060128 CITY OF CUPERTINO �;
BUILDING DIVISION PERMIT �,CON�TItACTOR,INFORMATION
BUILDING ADDRESS: J D HAALAND CONSTRUCTION I MITNb5060128
0163 JUDY AVE,
:R'S NAME: PERMIT ISSUE DATE
HENRY LO 19305 EL CERRO WAY
PHONE: SANITARY N0. CONTROL NO.
(831) 726-1577
ARCHITEC rENGINEER: BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
�Oo LICENSEDCONTRd under provisions
m 1 hereby affirm that 1 am licensed under provisions ofC odle. 9(commencing lob Description
�iW with Section 7IXIU)of Diviaion3of NC Busineuand Professions Code.and my license is
a« 1n GOB rated and effect. DEMO (E) HOUSE ��
5j2= Liccnm Cless Lie.#
af,o Da. Contractor CHG CONTR. FROM ABCO TOONST:I1,•TO`J�D HAALAND
R 1 CTS DECLARATION ti�1
W O I round my p a 1 W used u public mcords
n
y L cat. a
5 ER-BUILDER DECLARATION
< 7005
F 1 hcrchy air, Nm I am cacmpt from the Commnofs Poen.Law for the
O o following mason.( on 7031.5.Business and Professions Cole:Any city or county
which requires a permit to construct,alter,improve.demolish,or mpair any structure 16J�II rf r ' 1 I
prior mire issumm.alm rcquirn Nc applicant lorsuch permit to Glc asignedsulemenr .J
E£ < Met heisliccnuJpursuamrothe pmvisionsofthcConuacmr'sLiccnmlaw(Chepmr9 Sq. Ft. Floor Area wa'a�UU \jall( t1o000
Y� (commencing with Section 7")of Division 3 of Me Business and Professions Code)of
E R$_ that he is cacmpt therefrom and the basis for Me allcgcd exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy Type
not mom than five hundred dollars(S30)). P Y YP
❑1,as owner of the propmy,or my employees with wages is their sole compensation. 37507055 . 00
will do the worll,end the ewclure is hot intended art offered fonald(Sec.7041,Business
and Pmressions Code:The Cononcteri Lt..Law docs not ripply m an owner of Required Inspections
property who builds or improve thereon,and who daeseoch work him.lf or through his
own employees.provided that such improvements arc not intended mitlfercd forsale.It.
however.Ne building or improvement is mid within one year of completion,Ne owner
builder will new the burden of proving that he did am Wild or improve far purpom of
.1e.).
O 1,as owner,of Me prnperty,am caclmovely convening with licensed...am.to
construct the project(See.7044,Business and Professions Code:)The Conouwr's Li
tens,law does not apply.an owner of property who Wilds or improve demon.and
who contracts for such projects with a contnctor(s)licensed pursuant to the Conoacmis
Liecrtse law.
1 am exempt under Sec. .B&P C for this mason
r Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
O 1 have and will maintain a Certificate of Consent to self-insum for Worker'sCompen-
sation,as provided for by Section 3700 of the labor Code,for Rte performance of the
wart for which this permit is issued.
O 1 have and will maintain Worker's Compensation Insurance."required by Section
3700 of the labor Code,for the performance of Ne work for which this permit is issued.
My Workch Compensation Insurance artier and Policy number am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Obis tonin need nosbecomplced if the permit is for and hundred dollars($lett)
or less)
T unify that in to perfosmanec of Ne work for which this permit is issued,l shall not
emplayany persons any manner an to become ecome subject to the=77
artr oto vadon
laws of Califomi e¢
Applica t
NOTICETO AP n this CcniOcete of Ex p auld
bmamc auhjca m the Wo2cr ompcnsation previsions of Ne Lair C dd.you must
.,Z forthwith comply with suchisimu or this permi, he][W dcemcd revoked.
Z'O CONSTRUCTION LENDING AGENCY
I hereby vMrm that then iso construction lendingagcoc'y,far tM performenm of
a the work fur which this permit is issued Sc,,.3097,Civ.C.)
Irl Q lender's Name
7 Z Leader's Add.
C.)Q I certify that I have read this application and more that de eWsc information is
Iy ^F correct.I agree to comply with all city and county ordinances and sure laws relating to
p V building conswction,and hereby riuthmire repmxnudve of this city to enter Open the
0 W above-mdmioned pmpeny far inspaimme purposes.
(We).,me to save,indemnify and kcdp berml.the City of Cupertino against
F f%] habilitiea,judgmenb.eaab and expenses which may in any way accrue against mid City
U z Amm
PDL C sUNDERSTANDSof Me granting Of tAs Permit.
COMPLY WITH LL oN-poINT Issued by: Date
C ULATIONS.
Re-roofs
Signawr rApprcU��A
tit
OIN MATERIALS DISCLOSU E Type ofRoof
ore Wilding Weapons nam or handle havareous mamnalunicipal Codd.Chapter 9.13.and Nd Health and Safety
o All roofs shall be inspected prior to an roofing material beim
❑Yds , , ❑Na P P Y 8 g installed.
Will thea applicant or future Wilding If a roof is installed without first obtaining an inspection,I agree to remove
pp g occupant y A equipment rut or devices which g
emit W>ardnus air contaminants u Jcfincd by the Bay Area Air Quality Management all new materials for inspection.
District?
Oyes ON. '
I have mad the hasardouamaterials mquimmenu under Chaper 6.95 of thc Califor-
ria Has lth&Sof yCodd.Soctioru25N)5.35533ata 554.1un awdthatifthd Wilding
Jou not euemnt hasta main th it is my resppmibilitY to rwul'y the .pant of Ne
fail tssYhcnmaat, t OissuasecofaccrOfiateofOcd d Signature of Applicant Date
Owner ser o6hhor Nag ate
All roof coverings to be Class"B" or better