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02090057 (2) CITY OF CUPERTINO BUILDING DIVISION PERMIT Col—ti-10RINFORMATION Bull-11801NEsHILLCREST RD JIM NETZEL PFRMITN(02090057 rt71RI,M-HETZEL APPLICATIONUI 195' 2002 ( PHONE: SANITARY NO. 7 CONTROL NO. ARCHITECDENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICEhat I am ONIRACmR'S DECLARATION 0o Job Description I hereby affirm that 1 am licensed under provisions(if Chapter 9(commencing DEMO P �2 withlFoci, ndeffecDivi.einnJnf the Business and Professions CtNc,and myliccnsc is ^< In lull liircc and effect. X11 License Class Lim.Is OZ— Dam ContractorI S �^�'�� ARCH TECDECLARATION I understand my plansshall he used as public records O WOaDaV ij� Licensed Pnil'cssional OWNER BUILDER DECLARATION E 'ION " < ou u<Y 1 hereby affirm that 1 am exempt tram the Communes License Law for die !/\\) $7000 w_00 following mason.(Section 7031.5.Business and Professions Calc:Any city or county u $0! which acquires a permit w construct,altar,improve.demolish,ar repair any structure prior m its issuance,also requires the applicant for such permit to Tile asigned statement Ts �SS'�S< that he is licensed pursuant the provisions ofthe Contractor's License Law(Chancr9 �.v 1.�l�8Af©i� Valuation acF� (commencing with Section 4(XkBnfDivision J of the Business and Professions Cody)or is Nal he is exempt Nesofrom and Ne basis for she alleged exemption.Any violation N Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil Penalty of not more Nan five hundred dollars($54), A Occupancy Type as owner of the properly,or my employees with wage of heir sole compensation, will du the work,and the strunum is not intended or offered for sale(See.1140,Business and Professions Cade:The Contractors License Taw does not apply to an Owner of Required Inspections pmpeny who halt&or improves thereon,and who docs such work himself or though his own employees,provided that such improvements art not intended or offered for aide.If. however.the building or improvement is sold within one year of completion.he owner, builder will have the burden of proving that he did no,build or improve for purpose of sa1cJ. ❑1,as owner of the property,am exclusively convecting with licensed commcmm to convect the project(Sec.7044,Business and Professions Code:)The Contractor's Li . cense Law does not apply to an owner of property who builds or improves thereon,and. who contracts for such projects with a contracun(s)licensed pursuant to the Contractor's License Law. ❑Iam ca tirrld[t c. B&P C for his anon cr_ Dam )V d O KER'S OMPEISATIONDECLARATION Pr 1 hereby affirm under penalty,of perjury one of the fallowing declarations: I have and will maintain a Cenificalc of Consent to selbinsore for Worker sCompem sation,as provided for by Section 37W Of the labor Chile,for the performance of the wrr which this rmit is issued. IJ have and pewill maintain Worker's Compensation Insurance,m required by Section 3700 of the Labor Code,for the Performance of the work for which this permit Is issued. My Worker's Compensation Insurance carrier rid Policy member ale: Cartier: S'(L'(C r"J. 6r�licy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not le completed if the permit is for one hundred dollars(5100) or leas.) 1 certify that in the Performance,of fie work for which this permit is issued,I shall not employ any porsrm in any in a.Ln oyne subject In the Wnrkeri Compensation Laws of CelifarniaDatc tl s7 Applicata NOTICE TO APPLICANT:11;ofmr making this Ccni licale of Exemption,you should become subject m the Worker's Compensation provisions of the Labor Code,you must O 0 forthwith comply with such provisions of this purnitshall M deemed revoked. z CONSTRUCTION LENDING AGENCY F+ r I hereby affirm that there is a comu pity,lending agency lar the performance of be work work for which this permit is issued(Sec.3W7,Civ.C.) LW 0 Lender's Name, cl,D 2 I<nect.IAddres, 0 Q 1 comfy that 1 have mad this application and state that the above informationteupothe U C) cortect.l agree m comply have a all city a and cuuntand show ms,no,and state lows misting to QuJ alovenmeotioned construction,and for youthon purposes. rpresenmtivesnl this city memerurym the W abnvr(We)agree to ertysave for inspection keep ha (We)agree Io save.indemnify and keep harmless the City y CUPenst against liabilities,judgments,costs expenxs which may in any way accrue against said City U Z APPLICANT UNDERSTANDS e of thy,granting of tAND his fWILL COMPLY WITH ALL NON POINT Issued by: Datemy it. SOURCE REGULATIONS. Re-roofs Signature Of AppdicanVComractor Date, HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occultism store or handle haeardous material s defined by the Cupertino Municipal Code,Chapter 9.13,and the Ilcahh and Safety e.Section 35533(a)'I All roofs shall be inspected prior to an roofing material being installed. ED §Na Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hxmrdnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District'/ ❑Yee dNo I havereWth navNnus mamriaLs myvimmcnu under haPmf6.95OftheCalina- OZcalNl4SafctyC�ic.gwti 2TNL5.35 an H.I�dcrsund thatifthc huilding ares not curr��YYrl ave a imam, h 'N m ilii ,ify tM nvcupanI f the require which pend introit anceun a cyp cy. Signature of Applicant Date ownermaammiacd a, t ID All roof coverings to be Class "B" or better