02070061CITY OFCUPEWrINO
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1r:aanavx+l3t sayl,;xm..
nmunlrvc orvlsH3ry PERMIT
CONTRAC`"TORINFORMATI,
BuH1) L Fs .TEVENS CREEK BLVD
GEORGE G
HANSEN CONSTRUCT
O PITNC2070061
IIsNRQMNI KOBAIJASHI
303 OVERLOOK DR
APPLICATI9IP�'�ff® 2002
77 �S 77
PONE:
I Z
(831)338-2684
SANITARY NO. CONTROL NO.
ARCHMECf /ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am liacumdAer provisions of Chapter 9 (commencing
with SCninn ]1110 ofD ?nn Jof the BU. an n+ fmcivm:cgdg,rtedyn seis
TENANT IMPROV� °�E®
in full fore effect // O H yS�ry! (�LYY/
Li enw CY .e Lie. N
1 m •� — L Gantmc "'
ARCIIITi;CT'S Ii A N
'
FEB 0'4' 2003
I end erst yp tLxl I�rds
BUILDING
Licensed pn aid ..II
fURLDER
OOCNER DECLARATION
1 hereby affirm that I am exempt from the Cunhamore Licer. law for the
$60000
following reason. (Section ]1131.5. Business and Professions Cede: Any city nr county
which mgMm,%a permit to construct. a1mr, improve, demolish, or repair any structure
! prior to its ismance,alau require,ime applic,m forsuch pcmtiuo lilcasignedst Momma
that he is licensed pursuant to the provisions of the Cummemr's Liccow law(Chapter9
Valuation
(commencing with Section 71NNp nfDivis on 3 of the Business and Pmfcesions Cnde)'a
that he is exempt Meofrum and the basis for the alleged exemption. Any violation of
PI-TN
Occupancy T e
Type
Section 7831.5 by any applicant for a permit subjects me applicant to a civil penalty of
not MOM than Live hundred cutara(ssm).
102
- PIERS
0 I, u owner of the properly, or my employees with wages as their sole compensation,
will do the work, and me s.hm, is nos intended or offered for ule (See 71144, Business
And Professions Code: The Contactors License law does not apply to an owner or
Required Inspections
104
- REBAR
property he builds or impravea demand. and whoduessuch work himselfor though his
own employe,, provided but such impmexmenm au not intended nroRered far sale. If,
105
— ANCHOR BOLTS
however, Lie building orimprueement is sold within one year ofcnmpletion. the owner-
lO6
— SEWER & WATER
builder will have the burden of proving mat he did not build or improve for purpose of
gale).
202
- UNDERFLOOR PLUMBING
01, as owne r of the property, am exclusively contracting with licensed comracion to
203
- UNDERFLOOR MECHANICAL
constmet the project (Sec. 7144, Business and Professions Code:) no Contractor's Li.
cense wJasnmapplymennwnerufprupedywhobuilJSCrimprovesthemon .anJ
204
- UNDERFLOOR FRAME
whnc��reWUfmauc 'ecru withacomracan licensed pursuant m the Contractor's
205
— UNDERFLOOR INSULATION
me mptun&, e. B &PC fort ream
301
- ROUGH PLUMBING
act � Dam4 G
302
- TUB & OR SHOWER
WORKER'S O!PENdurIonDEC TION
303
- ROUGH MECHANICAL
achy aRrtn under penalty of perjury one ofm ollowing JUhr inns:
304
— ROUGH ELECTRICAL
]have and will maintain a Certificate of Consent to self-insum for Worker's Compere
3O5
— FRAME
sation, as provided for by Section 3]1X1 of the Labor Code, for the performance of the
work for which his permit is issued.
3 06
- HOLDOWNS
Q I have and will maintain Worker's Compensation Insurance, as required by Section
3 0 7
- INSULATION
3710 ofine Latina Code, for me gertotmance of me work fm which this permit is issued.
My Workers Compensation msimnee carrier and Policy number am:
308
- SHEETROCK
n.:
309
- EXTERIOR LATH
ILL CERTIFICATE COMPENSATION INSURANCE CEORRF.RS'
310
— INTERIOR LATH
(This seedinnneed not he complewd Rthe Frmit is intone hundred dnllars(SIBIa)
311
- SCRATCH COAT
313
- ROOF NAIL
I certify that h the performance of the work for which this permit is issued, l shall nn
501
- FINAL ELECTRICAL ENERGY
employany persnnt ann act h'nmeyt itothe Workers' Compensmi
Laws o�f CteliR+m' c O �I
502
503
- FINAL PLUMBING ENERGY
- FINAL MECHANICAL ENERGY
auppi
of VIA TOAPPLICANT: If. afar making thiscerulcam of Exemption. you hold
veto
504
- FINAL BUILDING ENERGY
forthwith comply with such provisions or this pcamit shall he deemed minded.
505
- FINAL ELECTRICAL
CONSTRUCTION LENDING AGENCY
506
GAS
I hereby affirm that there LS a conswction lending agency for the perfomanceof
- TEST
me work for which this permit is issued (See. 3097, Co, C)
Lender's Name
5 0 7
508
- FINAL PLUMBING
- FINAL MECHANICAL
Lenders Address
I cenify that 1 have read this application and antic that the above L ormation is
509
- FINAL GRADE
correct, l agree to comply with all city and county ordinances and state laws relating to
5
FINAL PLANNING
building consmie ion, and hereby aulhorix repmsem adves of his city to enter upon the
shave- mentioned property for inspection purposes.
14
FIN BLI W RKS
(We) agree to save, indemnify end keep harmless the City of Cupertino against
liabilities. judgments. costs and expenses which may in any way accrue against mid City
in consequence of the granting of this pemtit.
v
APP (CANT ERSTANDS D WILL COMPLY WITII AL NONPOINT
Issued by:
//
Date
S RCG R A I
-roofs
Type of Roof
Signam nl Apphcam] vactnr I arc
H ARDOUS MATERIALS DISCLOSURE
W ill me applicant or future building a cupant store or handle hmamous material
defined by the Cupenioo Muni ipa de, Chaplet 9.12, and the imidu and Safety
Ie. SCmion 25532(a)?
All roofs shall be inspected to any roofing material being installed.
El Ycx
prior
t
If a roof is installed
without first obtaining an inspection, I agree to remove
Will the applicant or I , hui]it sv pant use ryuLParent or devices which
emit hazardous air eumaminams as d ed by me Bay Arc, Air Quality Management
all new materials for inspection.
Distrin%
❑Yes o
Ithavercidiffic hnaarduusmaeriulsrequirementsunderClmpmrfi95ofineCalifm-
c Curie, s 55115,25533and unJeoifthe building
doe,ne, Len
Jas not c'umc ha eten mit is my rcaq+mihility to nod' her p tnf
obilil tore
hic be mprimtuisvuan cent. Ccnificamol'Gee
Si ature of Applicant Date
All roof coverings to be Class "B" or better
aw rmrtved gent D, e