04070073 CITY OF CUPERTINO -
BUILDING DIVISION PERMIT CONTRACTORYNNU_RMA'IITON;
BUILDING ADDRESS: HANSON CONSTRUCTION CORP PERMITN%4070073
77_�l OAK MRAWW CT
OWNER'S NAME: PERMIT ISSUE DATE
ARNOLD & LAV
:E: SANITARY NO. CONTROL NO.
(408) 517-0100
ARCHITE
8 517-
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
U00 LICENSED CONTRACTOR'S DECLARATION lb Description
xm F 1 heresy afOmi that I am IittvW under P wWOM of Chapkr 9(CrmmeMo
ing
MU with Semi., IXYJ)of Division 3 of Ole Busin�Csand Profcssiam Code.and my license is
iii nIc^x defrabNICNI( yp0 S176C7 ADD 321 SQ. FT. FOR KITCHEN/LIGHTS/REMODEL
mss„ Dak d 3`1� �D 4 C6nuxm, So/f Cchsro' C77o
ArshaliE ATION
I undcntanJ my plans shell W used as hlic rtcnrds
7C.
a In Licensed Professional /
3 OWNER-BUILDER DECLARATION
.�<I I hereby affirm Nal I am exempt from the Convenors License Law rot the
ipC following reason(Sccuon 71131.5,Buimesand ProresdaM Code:Any city or County
which requires a Permit to Construct,alcor,Marren,demolish,or repair any structure
prior m its issuance.also requires the applicant for such permit to Ole a signed smmment
t�< that Imislicensed pumanunmeProvisions ofthe,comncrohli¢MeLaw clopter9 Sq.Ft. Floor Area Valuation
F�F,G (commencing with Section 7")of Division 3 or the Business and Professions Code)or -
$ Out W is esempt therefrom and the basis for the alleged exemption.Any violation of $150000
Section 7031.5 by arty applicant for a permit subjccu Ne applamt 1.a civil penalty of APN Number Occupancy Type
not mare Nan Five hundred dollars(M).
P Y YP
❑I,m owner of the pmpcny,or my employcw with wages M their sol,compenutim,
will do tW work,end the smurert u natinkMed aroRerW Tarsale(See.7044,Buurcu
and Profession code:The num
Coscrs Licanre m taw does an[apply an owner or Req yid Inspections
property who builds i improvuch Improvements
and who sue not nuood himxd(m Nmugh his
however.the
pr sato imps mid witrartnot icar ofcdoroQered Tarsale.If.
builds Nc building atimprovementishat within one yam or completion,Ne oose of
builder will Mw Ne Wrdan of proving that k did not Wild or improv for purpose or ��
ulcJ.
❑1,u owner of the property.am exclusively contracting wit BecMW contractors to �/1�
Construct the es net (Sec.7044,Business and y who onsbui Cotler)The Contractor'sancon.and
sem(®` e'// _ O
ewelawdoesamtapply
cm ithaorprpeny who buildsorimprowa Nemoa.and `/7/II(�JO`Ap►v l3( 0
who contracts for pmjccu wiNaconmcmr(s)licensed pursuant in me Conuacmta ® O
Lleeuk taw. ■
❑I em exempt under Sec. .B k P C for this..on
Owrer Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pcMlty of perjury one of Ne following declarations:
On and will maintain a Certifiuk of Content in self-insure for Worker's Compact.
moon.as provided for by Section 3700 of the Inbar Code,for the performance of Ne
work for which this permit is issued.
0.1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of Ne Labor Code.rm Ne performance of the work fm which this permit Is issued.
My Workers Compensation lrsuranm,Cartier ,Polk numta, are:
V SC I Pal F6 /Ya9/ deer
CERTIFICATEOFEXEMMON OM WORKERS'
COMPENSATION INSURANCE i
fills section need not W completed if the permit is for onchundroddollars(5100)
of leu.)
I certify Nm in Ne performance of the work for which this Permit is issued,l shall net
employ any pcmn in any mannerso as m become subject to Ne Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT.If.after making this Cenificate of Exemption.you should
become subject In the Workers Compmuation provisions of the labor Cade,you must
.J,z fonbwith comply with such provisions m this Permit shall W deemed ranked.
Z O CONSTRUCTION LENDING AGENCY
I--m I hereby Nom that thm a is a cmuwninn]ending agency for the omfurmane,of
C' the work for which this permit u issued(Sec.3097,Ci,C.)
Q Lender's Nam,
=z lender's Address
U C) I Certify Net I have read this application and auk that the above infommauun is
U.P rorreca I agree to comply with all city and county Ordinances and stile laws relating in
0U building construction,and hereby auhorio,representatives of this city to enter upon lW
ahaveunkmidgm pmlaent for inspection purposes
F C (We)agree m saw,indemnify and keep harmless the City of Cupertino against
h incoabi ncecrence ftheStanding of this
May tany wayaccrue agalnst.tid City
U z A APPLICANT
of UNDERSTANDS
of Nis D WI
^ APPLICANT UNDERSTANDS AND WILgCOMPLY WITH ALL NON-POINT Issued by: Date
PSOREGUS. Y//Q 9 ae oyRe-roofs
HAZARDOUS MATERIALS DISCLOSUREType of Roof
e applicam or rutum building occ, mm or nandkhar ousanumnal
u defined by tc Cupertino Mume 1 Cade.Chapkr 9.12.and Nc Hu1N and Safety
end,.Section zss3z(a)?
p res o All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an agree to remove ins ection,I
Will the applicant or forum building accupam tax equipment or Jevims which P
m hazardous air comamina.Is as delmod by me Bay Area Air Quality Management all new materials for inspection.
mitt?
❑Yes u
1 have mad the havardnus makrials n1oimmcnu.mk1CW,nc,6.95 arta Calif.,
ria Health Sarmy Cadc,Scow 25505,25533 and 25534.1undcrsmlM Nu ifte Wilding r t
does not anenOy haw a knanL that it u my responsibility m nouly the occupant or t,
mqui en wnel,tuulacnoC[ppn,,r�miss ceoraC,nlrmakorOceuaney Signature of Applicant Date
' .U%-G:f Qd3 0
Ownramhomsdagent oak All roof coverings to be Class "B"or better