06050003 CITY OF CUPERTINO o, •'
PERMIT
BUILDING DIVISION n "
BUILDING ADDRESS: mA PERMIT NO.0 6 050003
21135 HAZELBROOK DR
OWNER'S NAME: FERMIT(SSUEDATE
EDITH ONG
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I0o LICENSED CONTRACTOR'S DECLARATION Job Description
bFy 1 herby affirm that 1 am licensed under provisions of Chapter 9(commencing
S with Section 7000)of Division 3 of the Business and Professions Code.and my license is
y in full to=and affect. SFDWL-2 STORY 3 , 813 '. /GARAGE 601 '
License Close Le'R (1ST FLR 2 t ' t
�- 427 /PORCH 20 /2ND FLIT 1366 )
t- Dau Contractor ,
ARCHITECTS DECLARATION
J�< I undorsunJ my plans shall he used as public records
eyU
W Licensed Profcsional
ty3 OWNER-BUILDER DECLARATION
i I hereby
aRsm
that 1 am exempt from the Contractor's Licenso Law for the
:c c following reason.(Section 7031.5.Busi cum and Profus(mu Code:Any city or county
Me
which requires a permit be construct,slut Improve,demolish.or repair any structure
'may prior to its issuance,also requires the appluxul(OrSuCh permit n fire a signed statementFt.floor Area Val$ZM1276
E< that he is licensed pursuant to the provisions,of the Contractor's License law(Chapter 9 Sq.
7�m (commencing with Section 7000)of Division 3 of the Business and Professions Code)at
? Out he Is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit eubAcu the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). 32628051 . 00
❑1,u owner of Ne pmpmty,or my employm wi0 wages as Heir sole compensation,
will do the work.ini dmimcome is not Mended moRered forsele(Sec.W ,Bunness Required Inspections
and Profesnom Cade The Contrennes License Law does sot apply a an owner of q P
property who bu ilds or improves daemon,and who does such rent himself or through his
macmploycrs,provided Nonsuch improvements tie not wended"ofered for We.H,
however.the building or improvement is sold within one year of completion.the mour.
builder will have the burden of proving that W did net build or improve for purpose of
pie.).
KL as owner of the property,am aselmovely convening with licensed contracted,e
nmm Ne project(Sec.7044,Buehsess aM Pro(etalons Code:)The Contractor's Li- -
cense Law not apply a an owner of property who Wilds or improves daemon,pd,
who can far such projects al tramorts)Incensed Pursuant ratite Canuxer',
Lean¢
❑Isms antler Se .B&PCI rNis o
owner Dao 30 6
WORK PENSATIO DECLARATION
I hereby affirm under penalty of perjury of Ne following declarations:
nam and will maintain a Certificate of Co ntaoself4diueforNumimesCompen-
.d.,asprovided far by Section 3700 of Ne Code,fm the performance of the
work for which this permit is iasueC.
❑I have and will maintain Worker's Compensation Insurance.as inquired by Schon
37W of the Labor Coda,for tire performance of the work for which this permit Is issued.
My Worker',Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' _
COMPENSATION INSURANCE
(This section need nut W completed!film permit Is forona hunNedtlallars($1001
or Itax)
1 century No c performance of the york far which Npermit is ipmd,I shall not
employ anype many mannc, m u 'ec n Workeri Compcnsatian
Laws of Cili( e
NOTI ant
NOTICE CA eking this Cenifi a of FLabor cad you Mould
become so jet to the Workers Compensation provision of the Labor Code,you most
,JO forthwith comply wit such province,or this permit sh Iheticemedoveked.
z ti CONSTRUCTION LENDING ENCY
(~" Ihemny alarm daat Nert uaconatrstcninnlendin agemylar Ne performance of
ai the work for which this permit Is issued(See.3097.Civ.C.)
W�Q Lender's Name
Z)z Lcndces Address
U Q I certify that I have mad this application and sate that the salve information is
f"Fcorrect.I agree In comply with all tiny and county ordinances and sum laws misting to
V building consvuction.and hereby authorize epresenutives of this city to enter upon the
W above-mentioned property for inspccuon purposes.
P. (We)agree to save,indemnify and keep harmless tie City of Cupertino against
rn Imbiliues,judgmenu,casts and expenses which may In any my aceme,against said City
(,)zm censer ...ilk granting of Nis
.. APPLIC UNDERSTANDS WIL COMPLY TH ALL NON-POI Issued by: Date
SOURC ULATI(
Re-roofs
Signe pplicanVConuec DB1 'Type of Roof
HAZARDOUS MATERIALS DI OSURE
Will ftVirlicamorfuum building occupam0 mha"ficharsolmsmaterial
as defined by the Cupertino Municipal Code.Cbapur .I2,and the Health and Safety
Cada,section x553za17 �r All roofs shall be inspected prior to any roofing material being installed.
I ❑yes a If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant rex equipment or devices which
t hazardous air cone rmanu as defend by the Bay Area Air Quality Management all new materials for inspection.
DisuictT _/
❑Yes ®No
1 have mad the Wurdousmaurialsncquiremenu under Chapurd.95 trim Califon
ria &Safety Cade,Sects 5,25533 and 25534.I undereaud Natiftis building
done curtentiy hove a en 4""1 my re,pon 'lily a notify the msuppt of e
mqui whicnm t I no, 'so—, a fteamnice y Signature of Applicant Date
3s, d All roof coverings to be Class"B"or better
r or eulhorized agent Dau.