02110117 [CITY OF CUPF.RTINO •Wim,.+ meg.,•..BUILDING DIVISION PERMIT CONTRACTOWINFURMATION
ES' STELLING RD RICHARD HANSET PERMITNO2110117
tRT193MARD HANSET APPLICATIQlgsXEgpgqrY2002
INE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MPRH
C=
One,
LICENSED CONTRACTOR'S DECLARATION
aeu p I hereby affirm that 1 am licensed under provisions(if Chapmr 9(commencing DEMO Job Description
<i with Section 7000)of Division 3 ofthe Business and PromarionaCcule,and my license is
in full to=and effect.
t2' License Clue Lic.g
Oz�m Date Contractor
=zARCHITECTS DECLARATION
g s< 1 understand my plans shall be used as public records
a0ad
B a Licensed Professional
FLL0 OWNER-BUILDER DECLARATION
ae ti a Y 1 hereby affirm that 1 am caempt form the Conumctor's License Law for the $15750
to S 00 following reason.(Section 7131.5.Business and professions Code:Any city Or county
an$� which requires a proof to construct,alter.improve.demolio.Or repair any SmXmm
print o its issuance,also requires the applicant for such Permit to file a signed Statement
that he is licensed pursuant to(be provisions of the Contractor' 3$191321F16Ga A@9 Valuation License Law 9 ,^"4
I (commencing(commencing with Section 70X8 of Division 3 of the Business and Professions Code)or
Wthat W is exempt therefrom and Be bazis for the alleged aemptioa Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not ($50%more than five hundred doll..(ssdA Occupancy Type
❑ h as owner of the p rpeny,or my employees with wages as their sale confirmation,
will do dte work,and Ne suvcture is not intended or offered for ale(Sec.7044,Business
and Professions Code:The Communes License law does not apply to an owner of Required Inspections
propeny who builds or improves thereon,and who doessuch work himseff or through his
own employees,provided that such improvements are not intended or offered for aide.IL
however,the building or improvement is ahl within one year of completion,the owner, .p�v e�x
builder will have Be burden of proving that he did not Wild or improve for purpose of I- as/'f L�
ale.). a s
a owner of Ne progeny,am exclusively contracting with licensed contactors to DEC* O 2002
consumer the project(Sec.70,14.Boomeas and Professions Code:)The Contractor's Li
cense Law does not apply to an Owner of propeny who Wilds or improves themon,and
who commets for such projects with a comracmr(s)licensed pu.uanuo Be Contractor's
License Law.
❑ 1 on exempt under Sec. ,B&PC for this..on BUILDING
into Dan 711LI 5/_� BUILDING`1
WORKER'S COMPNSATION DECLARATION
1 hereby OEM under Penalty of perjury,one of the following declarations:
[9.Po w and will maintain a Coni ficale of Consent to self-insure for Worker's Compcm
sation,as provided for by Section 3701 of the labor Code,for the pRormance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensmirn Insurance,as required by Snlirn
3700 of Ne Labor Code,for the Performance of the work 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 he completed if the permit is linens hundred dollars(S101)
or lcssJ
I ccnify that in the performance of the work for which this Permit is issued I.shall not
employ any pcomn in any manner.m asitt he44'ome suhlect to the Workers'Compensation
Lawsrf California Dare ly— f —OZ �/ .
Applicant
NOTICE TO APPLICANT:IL after making this Campeau,of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you mus
O O forthwith comply with such provisions or this permit shall M deemed revoked.
zCONSTRUCTION LENDING AGENCY
I hereby allirm tom there is a consroaion lending agency or the performance of
Gi .fir the work for which this permi t is issued(Sec.303,Co,C.)
aA Lender's Name
a Lender's Address
U O I certify that I have read this application and Sam that the above inlnmminn is SJ/
0 U comcm.l agree m comply with all city and ummy ordinances and matt laws relating a
U an..ngcotioned roend hertbyauthopa reprcumativcs of this city menter uMm the
26 an..mentioned(We)
a re property for inspectionmifyapurposes.
(We)agree to ave.indemnify and keep hay in a the City Of Cupertino id City
y liabilities,judgments,of
noting
ofI a pswhich may in anyway accmc against said City
U z A PLICAcnec of the g.ming ofthis perm J -01-
SOURCA TANDSAND ILL COMPLY WITH f/LN�-POINT Issued by: Dale 11�/
SOURCE U Ns.
Q( nA [ 9 OZ Re-roofs
Signature w9ppGcam/Contracrof Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hazardous material
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25SR(a)?
❑eta All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building Occupant ase equipment or devices which If a roof is installed without first obtaining an inspection, I agreeto remove
emit hazardous air contaminants in defined by the Bay Arca Air Quality Management all new materials for inspection.
Distdct? ,.,
C3 yea QK6
1 have real the oaoamous materials requimmena under Chapter h 95 of the Calror-
meHealth&SocyGxC,Secuon 25515,25533 and 25534.Iunde.mnd tom if the building
thrs not cuSmmly haw a tenant,that it is my responsibility in notify IM occupant of thea
requirenet ch musMmc riora,issmens.ofeRnifiemeofQcrancy/ Signature of Applicant Date
Owner or authorized agent Date p
i " 2 All roof coverings to be Class "B"or better
D