03100223 CITY OF CUPERTINO •� ��
BUILDING DIVISION PERMIT CLONTRACTOR INk�OIZmA TION:
EU DINGADDRMS: M.L.NIELSEN CONSTRUCTION I FCgMITND.03100223
R'S NAME: PERMIT ISSUE DAM
NO T
ONE:
SANITARY 0. CONTROL NO.
ARCHITEC iENGINEER: BUILDING PERMIT INFO
BLDGELECr PLUMB MECH
E
0 0 0
+,+tutu LICENSED CONTRACTOR'S DECLARATION JobDescri tion
UC 1 hereby affirm Nat 1 am licensed under provisions m Chapter 9(commencing P
b wif it roian]d If Oivision3orthc Busincv and Profcssiuns Codc,antl my liccnx is
n�crmon mrPe a"dere REMODEL (E) BLDG
Daenac Cl Contract.F Dam Ctun
vij� ARC ICS DELL
ATN
J
nany public awards
4/28/04 PERMIT APPL EXTENDED TILL 10/30/04
3
,ot; Licensed Professional
OWNER-BUILDER DECLARATION
F 1 hereby affirm out 1 am exempt from the Comment's License Law for the
❑O following mason.(Section 7131.5,Business and Professions Code:Any city of county
x m which requires a Permit to construct,alter,improve,demolish,Or repair any structure
FIQ
prior to its issmnce.also requires the applicant for such permit to File a signed statement
that he is licensed pursuant o the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
QFC (commencing wife Section 7")of Division 3 or the Business and Pmrusinns COd.dm
to Nat he is nation therefrom and Be basis for Ne allcgcd eaemption.My violation or S80000
Section 7031.5 by any affluent for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars($500). - ,
r
0 1,as owner of the pmpmy,or my employees with wages as their sole compensation,
will do fee work and Nestrmanc h not intended moffcted for sale(Sec,7044,Business 316 .36205
and Pmceel..s Code:The Contractor's License Law it=net apply to an owner of Required Inspections
pro.a emywho loy.,,lromimpmvasch improvements
doessuammut!.wite muffiedfar ]a his
ownemployees,provided Natsuch improvements seeoatch word sermrcemdfo,uie.is
however,Ne building or improvement I,said within one year mf completion,the owne,
builder will base the burden of proving that he did not build or improve for purpose of
sale.). 10
I,as owner of Be property,,B since exclusively Protracting wide licensed contractors i. 000" ,
construct the projectpply to 0n Busineuand ProfusionsCode:)TheConncome.Li.
c Iawdounot
uch apply roan with
of property who
camsoddsorimprovu income. /
who contract for such projects with a contractor(s)licensed pumuam to the Contxtoh
LicensearLaw.
1am /
1 exempt under Sec. ,B&P C far Nis moon /
er Data V�
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Nulty of perjury rote of the following aecluations:
Iva and will maintain a Certificate rf Consent to self--insure for WorkersCompen-
sration,as provided for by Section 3]00 of the labor Code,for the Performance of fee
work for which this permit is issued.
0 I ban and will maintain Worker's Compensation Insurance,as;required by sitcom
3700 of the labor Code,for the performance or the work for which this Permit is Issued.
My Worker's Compensation Insurance carie,and Policy
/ are;
,pan
y / / OCarrier. �A( C �ICATEOFEXEMPTIONFROM ORKER
-
COMPENSATION INSURANCE
r3eisacmimt rretl not hecomplcmd if the permit Is fortune hundred dollars($I0(B
or lesaJ
I certify that in the perfurmance of Ne work for which this permit is issued,I shall not
employ any person in any manner so u in become subject to the Workeri Compeuadon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Caniacate or Exemption,you should
become subject to the Worker's Compensation provisions or the Labor Chile.you must
.J O foMwith comply with such provisions or this Permit shall M deemed ranked. .
y^a CONSTRUCTION LENDING AGENCY
(~wN-' I hemhyafBrm that there isaconstatmLion lrndingagm¢y for But parurmmter of
6i > to work fur which this permit is issued(Sec.3097,Civ,C.)
W4
Q Lender's Name
0 Lender's Addrus
J O 1 certify that 1 have read this application and sate that the above information is
IL corral.1 agree to comply with all city and county malt unces and sate laws minting to
GU building commuctron,and hereby authorim reperanatives of this city to enter upon to
(Sts above-mentioned property far inspection P.M..
G (We)ugme to save,indemnify and keep humleu the City or Cupertino against
ti N liabilities,judgments,cosy and rspenses which may in any way accme against said City
(„)7 in cone vena ror the looming of this Permit.
e1— AP U ERSTANDS AND WILL COMPLY WITH ALL NON-POINT' ISSUCd by: Date
SOU CER' LATfONs.
ems-- '(A Re-roofs
JD'isOCO
umol' ppiicandConmctor Dem
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or fu um building Occupant store or handle havaraous material
imed by the Cupertino Municipal Code,Chapter 9.12.and the Hcalo and Safety
Semmn 255320)? All roofs shall be inspected prior to an roofing material beim
❑Yea ON.
P P Y g being installed.
Will the applicant or Boom building occupant use equipment or dcvims which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air contaminants as dcfrned by the Bay Arca Air Quality Management all new materials for inspection.
❑Yes ONO
I have mad the haeardousmamrials mquimmem s under Chai mr6.95 of the Califor-
nia Health&Safety Code,Sections 25W5,25533 md25534.I undersand thwif dM building
docs mently ham a mnanr,out it is my rcsponsihility to notify the mmpam nr Nc
mqu men w 'chm metpdorai,sumccoraccmnetoacorupmcy. Signature of Applicant Date
owm maummrixraalen, Due
0r1 All roof coverings to be Class "B" or better