04090095 CITY OF CUPERTINO "�" r `xsr 5
BUILDING DIVISION PERMIT CORACTORtNFU^ ,rTION.�':.
euaDING ADDRESS: HALLMARK CONSTRUCTION INC PERMIT N904090095
NER'S NAME: PERMIT MUEDATE
STEVENS CREEK
NE: SANITARY 0. CONTROL NO.
(408) 727-4422
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
L PLUMB MECH
AULAD Oft_F--I
1�
y o p LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm than 1 am Iiansed under pm lions mf Chapter 9(commencing Job Deseriptiof�
withSemlon] )of Divislon3ofthe Busirmu at..!..CmIlarmd my linen.is t�
;ffimmnm a Offe '3213 DEMO 19/j/1
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n t-4 Dam Comncwr /
❑ `` ARCHITECTS DECLA ATION /`/
i until l land my plans shell b,used u PuMicZR»Rf
Licensed Pmd'essional ONG
OWNER-BUILDER DECLARATION
1 hereby moo affirm on I am exempt from the Cemns Con Linen.Law for the
O O fallowing moon.(Section]1131.5, t.Business and improve.
demolish,
Code:Any city or county
A which requires a permit re cones;The alma improve,demolish,nr roam,any slmdum nnn
HZt met hePrior I.i uiensed prsuantuance.also to the NovisiocsOf for Onsuch Permittofilessigned eutemem
that tim escingwiJ Sectiotrothe provisions of Ne Conbscmr'a Lkense Law(C Cords)
Y Sq.Ft. Floor Area Valuation
$ (cat he is
(commencing tSec Trus and the
basis
3 of the Business and Profusions ladon tar
Natio u exempt therefrom and the baso for the alleged exemption.Any vlpenaon of
Section 7031.5 five
airy applicant fora permit subjects Ne applicant to a civil penalty of 3 2VPbU 1Fmbcr0 0 Occupancy Type
not mart Nen five huntlrtd tlollan(5500).
0 I,u owner of the pmpody,m my employee with wagu u their mlc compenaadon,
will dolhework.and the ire Comucans mnEede U.w diafontapply.to An
of Required Inspections
proand anywhiona Code:The Conmecton,License Law dors not apply N an owner is q P
own enywhobeiIdaored theveh NempOandwhoareasueh work omselfor through his
own employees,ping or
improven such ement
not ouofderoRemd groomer-
however,Nc building or improvement ie hold within ore year or completion,groomer-
builder will hew the burden of proving Net he did not build Or improve for purpose of
.in I.
0 I.As owner of the property.am exclusively contracting with licensed antrecmn to
construct Ne project(Sec.70",Buslm be and Professons Code:)The Conmumri Lt.
contain Law doe not apply to an owner of property who builds or improv lineman,And,
who contracts for such projects wits a contractor(s)licensed pursuant an the Contractor's
License law.
❑I am exempt music,Sec. ,B d P C for this..an
net Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of dm following declan0ons:
I he and will meinuin aCeniOcateof Covent N.If-insure for WorkerlCompen-
satub.u provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued
❑1 have and will maintain Worker's Compensation Insurance,u required by Sudan
3700 ofthe labor Code,for the perfermanceof dm work forwhich this lentil is owed.
My Worker' C�'^Pen,teen lnhunnm errior and Policy number am:
Ore rK a Poli No.:
CERTIFICATE OF EXEMPTION 0 ORKERS'
COMPENSATION INSURANCE
(This motion need not hccomplemd ifthe Permit is forms,hundred dollars(5100)
sur less)
1 unity Was in are perfnrm.na of the work for which this permit is issued,I shell out
employ any person in any mortician u N become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,efmr making this Certificate of Exemption,you should
become subject in the Worker's Compensation provisions of the Labor Code,you must
.J,Z forthwith comply with such provianne or Nis .it hof be dcemesi revoked.
z O CONSTRUCTION LENDING AGENCY
I hemby affirm that there is a construction lending agency for the performance of
ai tho work fur which this permit is issued(Sec.3097.Civ.C.) '
W�Q Lender's Name
Z Lender's Address a
U 0 I cerdfy that I have mad this application and sum that On above information is
E' contact.1 agree to comply with all city and county ordinances and state laws miming an
0 C) building conatrumbor,and hereby authodm mm mnutiv of Nis city N enter upon the
W ahavomenlimmed property for inspection purposes.
P. (We,)agree N save,indemnify and keep bumless On,City of Cupertino against
icy h liabilities,judgments,costs andexperts which may in any way ounce.,.last mid City
in consequence of On granting of this Permit.
APPLICANT UNPERSTD WILL COMPLY WITH ALL NONJ'OINT Issued by: Date
SO �� �� 7
Re-roofs
`Ignmure OnVCmnm xlor Dale r
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building acupantamre or handle,herardous material
As defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
wO,sono" All roofs shall be inspected prior to any roofing material being installed.
Yu 17aQo
Will,the appliem or fumm building Occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
[I mit harardous air contaminants As defined by On Bay Area Air Quality Management all new materials for inspection.
District,
❑Yes WO
I have mist the harardous materials requirements under Chapter 6.95 of the Califon
nia Haiti&SafctyCode,Reline 25505,25533 and 25534.1 undersand OR if the building
dors our cannotly h ve e mnanl Nat it is my mapowNility to nodl'y tic acup.,of the
require x In!Mo..ofardfieaefOc y. Signature of Applicant Date
rammorixndagent Dam All roof coverings to be Class"B"or better