03110018 CITY or cuPERTtNo *COIVTRACTORINFORMAT ON
aulLDlnc mvlslon PERMIT ,�1„ ._ 3.r:,n,,et?xw , ,;:. . ,
BUILDING ADDRESS: GEORGE G HANSEN CONSTRUCTI MIT N003110018
'NER'S NAME: 303 OVERLOOK DR PERMIT ISSUE DATE
-PIK 11/04/2003
(831) 338-2684 SANITARY NO. CONTROL NO.
ARCI11=1ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
100 LICENSED CONTRACTORS DECLARATION O O O O
£Z 1 Mreby affirm that 1 am licensed under provisions of chapter 9(commencing Job Description
< with See, ] )nfDivision3ofdmBusi!m spldPoolasiouCodc,andmylicenscs w� p
±E mmrs, dcffea ✓ 2 TI--DENTAL OFFICE F'��Yl+���®
s Z Dole
is Lia.X Corn T ��
ec FF¢ tlam 7S DEtor a' l�
L2 ON
1 underatand my plansahal Muadas Wit;card j�� as ZU9
>au y L 9
spG Licensed Paifessional
3
OWNER-BUILDER DECLARATION BUILDING
<Y 1 hereby affirm thatam exempt from the Contractors License Law for the
,0 O following mason.(Secdun 7VI1.5,Business and Pmfeadons Code:Any city or county
<$ Fwhich requires a Format to continuer,alter,improve,demolish,m repair any structure 8 O O O O
°ian riona m
its issuce.Atio rcquimsda.,,licam for such permit m file.signed statement
2 that he is licensed puromnuothe provisions Ofthe Contractor's Liu crat Law(Chapter 9 Sq. Ft. Floor Area Valuation
Z $ (commencing with Section 7")of Division 3 of the Business and Professions CsWc)of
that he Is exempt therefrom and Ve basis for are alleged exemption.Any violation of 36040028 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy Type
not mom Than eve hundred dollars(S500). - P Y YP
0 1,as owner of the painterly,or my employees with wages az their sale compensation,
Will do the work.and the nmcmre is not immutled or offered for sale(Sec.7094,Business
and Paifeado is Code:The Conuactorh License Law does not apply to an owner of Required Inspections
proPerty who builds or improves Vatican,and who does such work himself or through his
own employees,provided that such improvemcnu are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,due owner-
builder will loan IM burden of proving that M did not Wild or im prow for purpose of
tile.).
0 1,as owner of the property,am exclusively contracting with licensed convectors to
coavvct the procel(Sec.7094,Business and Professions Cout)The Conuacwr's Li.
come Law does not apply to an owner of pfopeny who builds or improves thereon,and
yiho contracts for such projecu with a contractor(s)licensed pursuant o the Cantnclor's
Lie seL w.
1 am naz
exempt antler Sec. B&P C for reon
nor Data
WORKERM
'S COPENSATION DECLARATION
1 hereby onion under Penalty of perjury one of the fallowing declarations:
I have and will muinmin a Cea ficam of Consent to o0f.insum fur Worker'a Compere
tion,a provided for by Section 3700 of the labor Code,for the puffaMance of the .
work for which Via permit is issued.
0 1 have and will maintain WOrtera Compensation Insurance,a required by Section
3700 of the Labor Code,for the performance of the work for which Via Permit is issued.
My rker's Compensation Insurance carrier and Policy number art:
Po11cANa�t _
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
(This section need not Mcomplaed if IM permit Is for one hundred dollars($1 00)
or leas.)
1 cenifY That in the Ferro ce pf the nor r�M1i this permit is iasucd.I shall nut -
cmplayanyperanniryp iserwazw m jot to the Wortcr'Cnm cmatio
Laws of Coliform yy/((/
Ap licam
N EFO P ]CAN a
F r.afte,inlikidilgiffterallm.C.of tem Phon,you should
M e ahjcn I the Workers Camposeaaion provisions of the labor Codc,you most
'z rMthwith comply with such provision or this Permit shall W dimmed invoked.
Z O CONSIBUC'nON LENDING AGENCY
I hereby affirm that Nene is a caatructinn lending agency for the Performance of
'Ya the.,it fur which this permit is issued(Sec.3!197,CN.C.)
21 A Lender's Name
= z Lender'sAddress
U Q 1 cenify that 1 have read this application and sum that the above information is 1
" P coneck 1 agree to comply with all city and county onfinances and sum laws relating to
0U building construction.and hereby amhorrae reprnenudve$of this city to enter upon the
ra atrovcmenliuncdpropertyst for;mnemes which in
(We)agree to saw,indemnify and keep harmless the City of Cupertino against
liobilitie.judgmcnu,ensu and expense which ma ; yway see vc against to City
U 7 in cansequcnee of he ing of this Perm'. /
r� APPLICANT UN TANDS AN IL MPLY R'ITH ALL NON-POINT Issued by: Daltre SOURCE REG IONS.
' ! Re-roofs
signyn p % nuacmn Dam
J AZARDOUS M ERIAUS DISCLOSURE Type of Roof
rill applicant or future Wilding occupant$core or handle hazardous mamdal
U de0ned by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
codo.semaan 2ss3z(an All roofs shall be inspected prior to any roofing material b
❑Ym mNO
Will the aircon'in fuwrc hooding occupant arc ega;nmanl or devices which
If a roof is installed without first obtaining an inspection,
It haaaNna air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
mtricl?
DYm u
Ihavc read the haaNrmsAm.wl,,,,wq 'ffbd'oy"lo
rChapmr R95 ofthe Califoo-niaHcaWASafmyCad eeduundersand Vat if the Wilding
Jma not curtently a mnan4 nattily Ibc tweupanl of therequiremcna atMmecamorq:myp.nm�.,� Signature of Applicant Date
.on gen, All roof coverings to be Class"B"or better