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CITY OF CUPERTINOBUILDING
CO NTRAGTt1ItINFORMATION".
DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
21044 HAZELBROOK DR
JL CONSTRUCTION ENTERPRISES
oRl onoog'
OWNER'S NAME:
PERMIT ISSUE DATE
ONE:
A O. CONTROL NO.
(408)318-1531
ARCHnEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACIDR'S DECLARATION
JOU Description1
hereby affirm that 1 am loommed under provisions a Chapter 9 (c.mommems
with Section 7000) ofDlvivon 3 ofte Btstiness and Pmfeudons Code,amd myllccnse is
REMODL 2ND STORY DECK
inmlir°rreumefrem. 108
,
License CI Its.
Cm,mm
A CHn8C1-SDECLARATION �C
1 undnmanl my plans shall W used u Public rn=mN,
Li1mcd Profeedovl
OW NER•BUIIDER DECLARATION
I booby aRrm that 1 am ea=mpt from the Cr mnmors Liceme Law for the
following reason. (Section 7M I.S. Business and Prefcasiom Codc: Any city or county
which requloa a permit to cnrmtc4 alcor, impmvo, demulish, or repair any someone
prior In its issuance, alsu o,ores the applicant for such permit to file aaigned statement
dee Conuxor's license LaW(Chapmr 9
Sq. Ft. Floor Area
Valuation
thin be is licensed Pormuanl to the provisions of
(commencing with section 7000) of Division 3 of me Business and Professions Code) or
4 O 0 0 0
that he is exempt thereltwn and the basis for the alleged nsempdon. Any violation of
APN Number
Occupancy Type
Section 7031.5 by airy applicant for a permit objects the applicant m a civil potty of
"°'come than Rw bmdred Oo1Ws (ssod3
32655034.01
1, as owner of the property, or my employees with w.gv u Nab some compenssten,
- uired Inspections
will do the work. and the times 4 not intended erofreod Ims.m(Sec. 7044, Bum.Re
f. I.itsm e law dens apply m a" donam Of
and Pmfestiov Cock The Covuacom
9 P
property who builds a iminows thercon. and who does such wok himself or through his
mans employm, provided thusuch imprevemants u<not moment t maRelea forssle B.
however, Ne building m impeovemant is sold within one year of completion, me downer -
builder wits have the burden of poving that le did rot build or improve for Purpose of
sale.).
❑ 1, as owner of the property am exclusively contracting with licensed contractor In
construct the project, (Sec. 7014, Business and Professions Code:) The COnmactors Li -
cove law dm not apply in an owner of property who ammo or improves thereon, and,
who contracts for such projects with a com rs cter(a) licensed Foramens he die Contrae'1ora
Limine Law.
0' Idememptummo Sec. ,B&PCrathisreamm
owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby &from uMer penalty of pcijmy one of the following dcclaraunnc
1 have and will malnuin a Cenificeteof Covent oself-troth far Workers C°mpery
smon, u Provided fn by Section 3'R)0.f the labor Code. fm the performance Of the
work for which this Permit is issued.
I have and will maintain Worker's Compensation Issuance, a, required by Slednn
37W of the Laem Code, for the peR.rmanee Of the were for watch this perch is issued.
My WorkersCompensationInoranm artier and Policy ...her ere: __,�
Cartier. S I/I I E C� p Policy NO.: I6/:Z C .(-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nds scctlm need noted competed If Ile permit i, foram hundred dollm. (SIM)
m max)
1 certfy that I. We pufomuen. N IM work for which thi. permit is issued. l shall net
mod, any pmme I. any manrlLr se ai to become object in N= Wordier Comp =saint
Law, of California Dam
Applicant
NOTICE TO APPLICANT. If, afar making this Ccoifscam of Ezempti n, you should
become object in the Warners Compensation provisions of the labor Code yom muss
v forthwith comply with such provisions or this pormit "I be domed revolted.
CONSTRUCTION LENDING AGENCY
1 booby affirm ther Nem i, a lending agents for the pdrfamance of
ted (Sec. 30
' de wort for which Ina perch is tuned (Sec. 3097, Civ. C.)
Lenders Name
I<naera Aaam•.
"
1 ratify that 1 have need this application and mm that the &hove information is
ccmcc4I ague It comply with all pry and county oNUunm and sum laws relating o
Wilding commutation, and hereby antho me representatives; of this city to enter Open to
ahow-mentioned property for inspection Purposes -
(We) agree to saw, indemnify and keep harmleas the City of Commute agairm
raj li.bilhim judgmemu,mr;men eapenses whim may In any way nam° against said City
in concomitance of die granting of this permit
APPLI ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
r
Issued by: Date /0 --Lf ^ m'
50 EGUI�QIONS ,(..,e/
Re -roofs �c
Type of Roof
��
( fG
Signalpm of Apple ttConuamer Dam
HAZARDOUS MATERIALS DISCLOSURE
Will to applicant or future building acupa"t mom Or handle havoous mamrial
as defloed by this, Cupertino Municipal Code. Chapter 9.15, and the Health and Safely
Code. Section 25532(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑sen V.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or tom building oaupanl use equipment Or device Which
emit havakous air cenhamivnha as defined by the Bay Ares Air Quality Management
all new materials for inspection.
Dourict7
❑Yes �Nu
I haw read the Haan decs materiais oquvemmmu underChapmr 6.95 ofthe Califur.
nu Health& SalmyCode Semm 25505.25533 sell 25534.1uMmmand tan ifthc building
-
dm ret n y haw a mvnL that it u my responsibility in entry to moment of the
roq.i which hcnot prior iIssuance ofaemtUvmofpccupmt
Signature of Applicant Date
1642Da 1)
All roof coverings to be Class '%W' or better
OW1 Or Of amohdri agent