04040131 CITY OF CUPERTINO = '
BUILDING DIVISION PRRMIT CON�'I'RA.CTOR INPORMATION.'
�
BUILDING ADDRESS: PERMIT NcD4 0 4 0 13 1
20179 NRTHWEST SO
INF.R'S NAME: PERMIT ISSUE DATE
FREDERIC ERICKSON 04/20/2004
ONE: SANITARY N0, CONTROL NO.
ARCII=Cr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB 0 MECH
0 0
00 0 LICENSED CONTRACTOR'S DECLARATION Job Description
wz� I hcrchy affirm that 1 am licensed trod r provisions of Chapter Y(commencing p
<a with caiun7MEnf Division3milm Bu and Professions CnJe,and my license is
4 Lice as an "` -9 Lic« (0Op89L REPAIR BALCONY
^o
Data cn CONTTRACTOR: M.L.NIELSEN CONSTRUCTION
A SDE IDE ATION
�i 1 rand m pia is records
e
o
Licensedntfcssional
g OWNER-BUIL ER DECLARATION J
2<m 1 hereby affirm that I ore exempt from the Contracmrs License Low lot the
p O following reason.(Saaiun](131.5,Business and Profexeinm Cnde:Any oily nr county 0
K$1� which requires a Permit in construct,alter,improve,demolish,or repair any structure
LZi
Prior o its issuance,also myuims the applicant for such permit to rile a signed statement
gg < the,he in licensed pursuant 1.the pmvisionsofthe Cnntmctur'aLicense Low(Chaptcr9 Sq. Ft.Floor Area Valua 900
y $ (commencing with Section 7")of Division 3 of the Business and Professions Code)or
a. Not he is exempt therefrom and me basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500). 31639049 . 00 P y yp
❑1,As owner of the property,or my employers with wages As their sole compensation,
will do me work,and the structure is not intended or offered for sale(Sec.7041,Business
and Professions Code:The Contractor's License Law does not apply to An owner of Required Inspections
property who builds or improves mercon,and who does such work himself ar through his
own employees,provided that such improvements are not intended a offered for sale.If. _
however,the building or improvement is sold within one year of comPletion,me owner-
builder will have me burden of proving licit he did not build or improve for purpose of
sale.).
❑1,as owner of me property,am exclusively contracting with licensed contractors to
construct the project(Sec.7014,Business and Professions Code:)The Comraaori Li.
cense Law does not apply to an owner of progeny who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant o the Contrmetors
License Law.
❑1 Am exempt under Sec. B&P C for this reason
Date
WORKER'S COMPENSATION DECLAiATION
1 hereby affirm under penalty of perjury one of the following declarations: _
Ll'on,
ave and will maintain a Cenificme of Consent to self-insum fur Worker's Coni
As provided for by Section 37M of me labor Code,for the performance of the
for which this permit is issued.
ave and will maintain Worker's Compensation Insurance,as required by Sectiun
f the laborCode,for the performance of Ne work for which this permit is issued.
orker'sCnmpensatinlnsumnce copier and Policy�nu Mr art: �/'rr. RG
CERTIFICATE I o.: `a 7\
OMPE SATIONXEM AN WORK S'
COMPENSATION INSURANCE ,
(This section need not be completed irme Permit is for one hundred dollars(A(x8
or Icss.)
1 certify that in the perfumuncc of the work for which this permit is issued,l shot]not
employ any Im man in any manner so as to become subject to the Workers Compcnsmb ut
Laws of California.Dat.
Arid team
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you mus _
.J z forihwi th comply with such provisions.this Permit shall he dammed revoked.
zrO CONSTRUCTION LENDING AGENCY
[-+ Ihemby affirm that there is a construction lending agency for Parfurmance of
F>-r me work for which this permit is issued(Sea.30fr?,Civ.C.)
W� Q Lender's Name
D z Lender's Address
U 0 1 certify mat I have read this application and sure that me above information is --
f>rF correct.l agree to comply with all city and county ordinances and state laws palating to
OV building construction,and hereby authorin representatives of this city to enter upon the
W above-mentioned entopeny fond expenses
purposes.
gy (We)agree m Asia,indemnify and keep harmless the City of Cupertino against
notN incoitiequacro Of the coarsing expensesmit, may in anyway accmc against solaCity
V Z Aconuquencc UNDERSTAND1,11)
Permit.
AP ANT UNDGRSTAND ND WILL COMPLY WITH ALL ON-POINT Issued by: Da
RC LATIONJ. O
Re-roofs
Signature of AppliaatyContracmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building occupant amm.,ban Il arJous motorial
as defined by the Cupertino Municipal C c,Chapter 9.12,and the Health and Safety
de,Section 25532(x)9 All roofs shall be inspected prior to any roofing material being installed.
Q Yes
J Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit havardnus air contaminants As defined by the Bay Arca Air Quality Managcmcnt all new materials for inspection.
District? —/
El Yen �N
I have read thc hmarduus materials mquirements under Chapmr6.95 of me Califm-
ria Healer&Safmy Codc,SCNnns 255115,25571 and 25534,i unJerstantl thwif the building
does not curtenit hove a tenant, responsihility sea nndly the tusupam orthe
r pre o Ihmust 6 et or H a ccofaCcnifcatco cup aro Signature of Applicant _Date
OoAr,mramnarnedagem Dam All roof coverings to be Class "B"or better