07100106BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
21105 HAZELBROOK DR
OWNER'S NAME:
ARCHITEC IENCINEER:
LICENSED CONTRACTOR'S DECLARA770N
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
n full force and effect.
L cci= Class Lie. •
Date Contraotor
ARCHITECTS gECLARATION
I understand my plans awl be used as public records
Licensed Professional
OWNER -BUILDER E CLARATION
I hereby affirm that 1 am exempt f6m the Contaetoes License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requiref a permit to construct, alter, improve, demolish, or repair any atructum
prior to its issuance, also requires the applicant for such permit to rile a signed sutcmcnt
that he Is licensed pursuant to the provisions of the Convector's License Law (Chapter 9
(commenting with Section 7000) of Division 3 of the Business and Profesions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section-7031.5 by arty applicant for a permit subjects the applicant to It civil penalty Of
not more thao five hundred dollars (M W).
❑ L as owner of the property. or my employees with wages as their sole compensation,
will do the work and the structure Is not intended or offered for sale (Sec. 7044. Business
and Professions Code The Contracts IScerue Law does Dot apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
won employees, provided that such improvements ate not intended or offered for sale If,
however, the building or improvement is sold within one year of complexion, the owner -
builder will here the burden of proving that he did not build of improve for purpose of
L as owner of the property, am exclusively contracting with licensed contractors to
construct the Project (Sec 7044. Business and Professions Coda) The Contractor's U-
cense Law does not apply to an owner of property, who bands or improves thereon. and,
who contracts for such pmjects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec . B & P C for this mason
Owner Date 'A-1-7
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compers-
station, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued
❑ I have and will maintain workers Compensation insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
My Workers Compensation Insurance airier and Policy number am:
Carrier. Policy Nw
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred dollars (S 100)
or less)
I certify that in the performance of the work for which this permit Is issued. 1 shall not
employ any person in any manrrcr so as to become subject to the Worked Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after malting this Certificate of Exemption, you should
become subject to the Workes Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be da7ned revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
I certify that I have read this application and state that the shove information is
cormcL 1 ague to comply with all city and county ordinances and state lawn relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentimtcd property for inspection purposes.
(We) igta to save, indemnify and keep harmless the City of Cupertino against
IfabRities, judgments, costs and expenses which may in any way acme against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE R_ '�_
Signaw contractor Date
HAZARDOUS MATERfALS DISCLOSURE
Will the applicant of future building occupant store of handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
❑ Yes "JF660
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes No
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health &SafetyCedc. Sections 25505, 25533 and 25534. I understand that if tine building
does not currently have ■ tenant. that it is my responsibility to notify the occupant of the
of a Certificate of Occypancy.
Date
JEREMY MAO INC
1041 WINDSOR ST
(408) 449-9942
HOUSE DEMO
PERMIT NO.
07100106
PERMIT ISSUE DATE
11/05/2007
SANITARY NO.
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT
PLUMB
Job Description
Sq. Ft. Floor Area $15000 Valuation
32 62 8 0 4 9Agbl Number Occupancy Type
Required Inspections
Issued :
Re -roofs
Type of Roof
Date /�/ S
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
I A -I o7
Sign a of Applicant Date
All roof coverings to be Class "B" or better