04110034 (2) CITY OF CUPERTINO '�
BUILDING DIVISION' PERMIT CONTRACTORANFORMATION`Fl�. - - • - -.
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BUILDING ADDRESS: PERMIT NO.
04110034
—KWGGI3 BR
WNffR'g NA - PERMR kSSUE DATE
TAN CaLR21;ly
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SANRARY 48t OL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
.BLDG ELECT .. . PLUMB MECH
0 0 0 0
yap LICENSED CONTRACTOR'S DECLARATION - Job Description._
F - 1 Mmby affirm Nat 1 am limnum
d under provisions of Chapter 9(romencing - P
`ref with Section 9IXgp of Division Sof NC Business and Prefessiona Code.and my license is
n<
n in full force and effect.
ueenacClaaa tic.« ADD 266 SQ. FT. (FOYER)
='ca,' Dam ARCHITECTS DECLARATION Contractor CONTRACTOR: ALAN HAUSMAN CONSTRUCTION
he I uMcrsund my pI.m.haf M used as public ods
3LLU
D t; Licensed Pmfcasionai _
i 3 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from tM Conuacmr's License Law for the
p o following mason.(Section 7031.5,Business and Professioes Code:Any city or county -
x m which ma,l rte.permit m cnwruct.alun improve,demolish,or repair any structure
< prormitsiuuance.alwrequirestMapplicaniformchMmittofleasignedsutement
�t Nat he is licensed pursuant to Ne pmvisiou of the,Connector's lJmnu law(Chapter 9 Sq.Ft. Floor Area Val%T440
�t-a (commencing with Section]BOB)of Division 3 of do Business and profession;Cook)or ..
y Nat he is exempt Nertfum and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicator o a civil penahy of - APN Number Occupancy Type
not mart Nan live hundred dollars WWI.
❑ 36917052 . 00
-
willdo use work,end Ne iwcturt is nasinmMed oroRcred roseola(Sm.906a,Busimas
and Profession Codc:The Conmcurs Liatsae law does not apply on an Maker of Required Inspections - -
propenywhoWlldsmimpmvathereon,andwhodoss such work himaelmr through his _.
own employee,provided that such improvements are notina:nde4 oroRered fm sale.If.
however.the wilding or den of anent is sold within rote year of completion,Ne owe of
builder will have to burden of proving Net he did not build or Improve for purpose of -
saicJ.
&h as owner of Ne propenY•am exclusively contracting with licensed canbuu s to
construct to project(Sec.]Baa,Business and Profession Cade:)The Connacurs Li- -
who contracts law dma not apply u is owner of prnpertY who builds or impmvu Corton,and 2/
whoLfor projects with aconnacmr(a)licensed pursuant to the Comm�ora
0
License ons law.
I am exempt under Sec. B k P C for this reason - '
.net �Date r// O Y
WORKER'S COMPENSATION DECLARATION
1 beuby Nem under penalty or perjury ane of Ne f011owmg dmIM110 e
I have and will maintain a Certificate of Contin a self-insure for WorkersCompen-
ation,as provided for by Scmion 3?UB of IM labor Code,for Ne performance of the -
work for which this Permit is issued.
❑1 base and will maintam Workers Compensation Insurance,u required by Section ,
3100 of Jm labor Code,for IM performance cities work for which this permit is issued,
My Wa", Contra.....Inwnmx mrru and Policy number am: -
Canier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu inion need not Mcompleud Rule Permit is for one hundred dollars(SIQo)
less)
1 mniry Nat in the performance of Ne work for which this Permit u issued.I shall not
employ any permm in any manner an as to become abject to the Workers Compensation .
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to Ne Worker's Compensation previsions of CM labor Chile,you must
Z forthwith comply with such powimmot or this permit shall M decmcd umkcd.
z CONSTRUCTION LENDING AGENCY
I hereby affirm Nat there ge
is.construction lending ancy lshe e Peof....or
Ne work for which this permit is issued(Sec.3097,Civ.C.) -
{A Q Lenders Name
z lenders Addeess
U Q 1 cavity that 1 have read Nis application and sum that the above information at
(•^ cornmr.I agree to comply with all city and county orsiwtms and state laws berating 10
DU building construction,and hereby aumoriu repteaCOM s of this city he enter upon Nc
Fkl above-mentioned property for inspection purposes
(We)agree to save,indemnity and keep harmless 0m City of Capenmo against
liahilidef.judgments,costs and expenses which may in any way acervc against said City
of the
U z APPIL.CANT UNDERSTCCng of NDS ACs runit.
ND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU CEREGOLATI
��p :'!�? �C 'I"I " Re-roofs
-Srqboom afAppbaH ZSURBv/ARDOUSMATERIALSDISCLOData Type of Roof
Will Ne applicant or future building Occupant store or handle hmaedous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and tM Health and Safety
Cade,Semon 25532m? All roofs shall be inspected prior to an roofing material being Installed.
❑Yes 711 No P P Y g g
Will she applicant or future wilding occupant use equipment or devlms which --If a roof is installed without first obtaining an inspection,I agree to remove
,it harmdous air contaminants as Jeflned by to Bay Area Air Quality Management all new materials for inspection.
lame'?
Fl Y., No
I wvctmd the Mrardoum25505.255uadm SM.lu Chapter 6.95 ifNC Wilding �r /O'
nuFicalIham road Cu du Section 2550als requirements
eq 3andnts under
Chapvtl Naz ifthe building /�(// /--`{ v
Joe not cutrtndy hast a u mm.that it u my ropouihility In notify Jr=owl of the v
nopitemcnts whichmug met pd.,u issme�aracemream of occupan, Signature of Applicant Date
!� ;{ 0
or atohari.dagcnt Date All roof coverings to be Class"B" or better