04010065CTTY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:'-,.
BUB.DINGADDRESS:
9P RQRTNT')F.LT, WV
HUMRICH CONSTRUCTION
PERMIT"°04010065
ERS NAME:
PERMIT ISSUE DATE
CARL LAWSON
2999 WQQnRTnR Rn #21?
niJ14/2nn4
E.
SANITARY N0, CONTROL NO.
(650)369-0999
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
o
Job Description
under xravisiov Chapter 9 (commencing
I herehy affirm the' I em licensed M
psed
with Section 7W) of Division 3 of the Business and Professions Code, and my license is
I. full Claanderre
REVISION --IN HOUSE USE ONLY
License Class Luc. g
Date contractor
NO NEW PERMIT ISSUED/ORIG. #02060022
ARCHITECTS DECLARATION
I understand my plans shall be used Is public records
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Liccnttd Pm(cssinnal
OWNER -BUILDER DECLARATION
I hereby affirm 'hat 1 am exempt firm be Contractors License Law for 1M
following mason. (Section 7031.5, Business and Profession Code: Any city or county
which requites a'nah to eonstiucl, elm,, improvs, demnlieh, an .,.it any mmelure
Sq. Ft. Floor Area
aluatioq 107'
Poor in its issuance, also requires the applicant for such permit to Glc a signed statement
'hal he isli¢nud pursuant l0 the previsions or the Contractor'sI-cenm Law (Chapter 9
(commencing with Section 7") of Division 3 or be Business sad Prafasions Code) or
that he is exempt thererrom and our basis for the alleged exemption. Any violation of
Section 703 1.5 by any applicant for a permit subjects the applicant to a civil penalty of
APN Number
Occupancy e
p y Typ
not ream than five hundred dollars WOOL3
6219026.00
❑ 1, as owner of Ne property, m th
my employees with wages as their turn compensation,
will do the work. and he awcture is or intended or differed for saic (Sec. 7044, Business
Required Inspections
and Professions Code: The Contractor's Liecrrt , law does not apply to an owner of
property who buildsor improve themon, and who does such work himselrorthvugh his
own employees. provided that such improvements am not intended oro(road for sale. IL
however, the building or improvement Is sold within one year pf completion, the owner.
-
builder will haw the burden of proving that he did not build or improw: for purpose or
ole/..).
I 1, as owner of the property am exclusively mnus sting with licensed contactors to
construct the project (Sec. 7004, Business and Professions Code:) The Contractors Li-
.
cave Law does not Apply to an owner of property who Wilds or improves themon, and
who contracts for such pr*m with a conmmor(s) liunm t pursuant o the Contractors
License Law.
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❑tlameaemp' l sec. ,B& PC for Nia caused
1OT
WO.7f1R'5 CUM PENS 1NDECLAHATVIN
1 hereby affirm under penalty of perjury one of the following declarations:.
I haw and will meinuin a Ceniham of Conon' l0 sel6Wum fur Worker's Compere
sallon, as provided for by Section 7700 of tM Labor Code, for the performance of the
work for which this permit is issued.
1 haw and will maintain Workers Compensation Insurance, Is required by Section
7700 of the labor Code. far'he performance of lbs it for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if'he Permit is formrchundred dollars (SIM)
nr less)
I cenify that in the Perlormeooe of Ne work for which this Permit Is issued, I shall not
employ any orsn in any manner so a a In become subject o the Workers'Composallon
_
Laws of California. Dale
'
Applicant
!
NOTICE TO APPLICANT: IL aper making this Cenifteato of Exemption, you should
become subject o the Worker's ComPeneelion pvvisions of the Labor Cmc, you must
I
(oMwiN comply with such provisions or this Permit shall be deemed revoked.
.
CONSTRUCTION LENDING AGENCY
1 hereby e01rm that both is a construction lending agency for the perfurmame of
„
the work fur which this permit is issued (Sec. 3097, Civ. C.)
Landers Name
Lender's Add.
I cenify that I haw read this application end ttste that he shove oformuiun is
correct 1 agree to comply with all city and county ordinances and stsm laws relating to
Wilding construction, and hereby autharina repossare lives of this city to enter upon he
ed rte inspection
almYCicut.j d,nich
(We) agree 10 saw. Indemnify and keep harinleaa the City of Guper in0 against
,cost and expenses which may
may In any 'MyaCCNC against mid Glry
in of the gran
of the granting of this permit.
thismit.
A
APPLICANT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT
Issued by: Date
SOURCE EGULATIO - a r9: 0�
Re -roofs
tgna'ureof Appr ✓Conum'or Dam
HAZARDOUS MATERIALS DISCLO URE
Type of Roof
Will the applicant or future building occupant store or handle hevardous material
Is dcOned by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
I, Schon 2553200?
YaN9
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
it hammious air contaminants as defined by the Bay Amo Air Quality Management
all new materials for inspection.
islrict?
❑Yes (ItN.
I ban mad the hvardousmamriah, requirements under Chapter5.95 of the Caliror-
ads Hcalth& Safe'yCode, Secuons 25515.25533 and25534. 1undcrstand Na if the Wilding
docs not ci mcndy how a tenant Ne' it is my responsthili'y in ..silty the xcurynl M the
requirements wh'ch muss mel pdunuisvu ce ar aeeninested cup9r'L�A
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner d
no author . egcnl Dale I