04020116 CITY Of CUPERTINO BUILDING DIVISION PERMITCONTRACTOR�IN 'ORMATION
e17LDmc ApDDR�SS. UILLIAM HURT "hR4W620116
PERMIT ISSUE DATE
OW S AME
AM HTJRT :1740 ACAZAR AVE _., 04/29/2004
SANITARY NO. CONTROL NO.
k{ONE:
;83_11_633-4420
ARCWTECS'IENGINEER: { BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION
w❑ 1 helehy affirm the,I am becnud under powt,mor of Ch ter.,9(commencing Job Description
_Zbw with Section 7W)of Division 3 of NC Bus,oes and Profcssnsns Code.and my lore=is
«'inmBforceaNSttem DEMO EXIST. HOUSE
j t2 i License Clots/ L ,x
n—o
Dar, Cum n^
rq ARCH RATION
a 1 do tlU ff Min. ha; II M1C U — lY c rp A _
Lwcnx I Pm C'u Y^
OWNER-BUILDER DECLARATION
5 I hereby a1Erm that 1 am exempt from the Contractor's License Law for the
po folluwmgrcaon (Section 7131.5.Business and Professions Cole Any city or county
K e which regorca a pemit w consumes,alter.Improve,demolish,or repair any Strucmm _ _ _ �> 10000
prior u)nsrsstionce,also mywres the applicant for such Permit We a signed statement S Ft. Floor Area Valuation
that he is licensed pursuantlo the provisiunanf NC Comment's License law(chaPwr9 q
CFO (Commencing with Section 7p0)of Division 3 of the Business and Prefortmos Code).1
i
Our he is exempt therefrom and Ne bass for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects She applicant to a civil penalty or 357&VN lshlml6bld Occupancy Type
not mom Nan five hundred dollars n!i
❑1,u owner of the putt,noy,m my employees with wages u their sole c.mpcnsation, _. .-
wiltW ew.k,andNesv tocisnmmmndcdoro @mdf.,salt(Sec7Ni,BusinusI Required Inspections
and Professions Code.The Contanors License Law does out apply to an owner of q P
progeny who builds or improve Hereon.andwho doesauch work himself or through his i
own employr6,provided Nat&ueh Improvements arc not inunticd.rortcrrAforaalc IL
howeveq the
builtler wdl have the burden of promevnint g is Nsaal t he rlod om build oor f mmmpmplvC for p uCryOowu n eorf- ,
�
sale.),
�Q�1,a owner of the property,am"elusively Contracting with licensed contractors to
Tans I.,the protect(Sec.7B4d,Business and Professions Code]The Contractors U- ; A
ecese,Law does not apply m an owner,of property who Wilds or improves th.non,and - aV
who contracts for such projects with a c.mmclor(s)licensed PUSUOut to the Contractors
License Law.
❑lame pt ,S(ccLJI`' �C/ B&PCfor NU moon 1
m �ONKtR'S COM ENS 'TIAOTION
1 bemby a1Tner under pemity of pe jury°�-.°of Ne following tlalumml
I Onward will mainmin aCcmOcale of Coucnt(O xlf.insum(or Worker's Compcn- .
uon.u provided for by Section 37W of the Labor Code,for the performance of the
work for which this Permit is issued.
❑1 Mere M,will momaln Wwkci s C.mpensatmn t....eme as¢ywred by known
T!W of the Labor Code,for the performance of the work for wh.wh Cos permit Is issued.
My Worker's Compensation Insurance carrier and Policy number am: -
Carricr: Policy No
CERTIFICATE OF EXEMP.ION FROM WORKERS' t
COMPENSATION INSURANCE
(This account need not be completed itthe fermis is Rome hundred dollars(Slot)
or less)
1 eemfy that in the pcffnmumc of the work for which this Permit is issued,l shall not
employ any Person In any manner so u to become subject to[be Workeri Compensation -
LawsofCalifornia Dar I
Applicant
NOTICE TO APPLICANT:If.at making this Cemlicaa:of Exemption,you should
become subject to the Worker's Compensation pmwmns of the Labor Code.you Most
.J z forthwith comply with such Provisions m this Permit shall he deemed revoked.
z O CONSTRUCTION LENDING AGENCY
[[-. a---• I berehy aRrm Nat NCI=is a emodure on lendmgageney for the PCffomance of .
7i 7 the work for which this permit is Issued(Sec.307,CO,C.)
L[1 Lender's
Nish—,Z Lenders Addre- \
L)O 1 certify that 1 have read this application and sitM that the a Wve mfonnatim is
F torten.l agree to comply with all city and county.Nmannes and slate laws relating in
C)U Wsldmg consnvnson,and hereby authmim repmamalive.of ben arty m noun....0 the -,
D.1 ahovomenbonerl property for inspection Purposes
C. (We)agree to Pere.Indemnify and keep harmless the City o(Cupcnma against
F' ,r, babilmea,judg menu,costs and expenses which may many way accmc litmolstep City
U in consequence of NC granting of Nt permit
.y APPLICANT NDERSTANDS t WILL COMPL WITH ALL NON-POINT Issued by: Date
SOURC TlDNS
/ 1p � Re-roofs a /
Sign 6cofAppuan on�uaelor Date
HAZARDOUS MATERIALS DISO OSURE Type of Roof
Will due applicant or future budding Occupant state or handle hazardous match&]
an defined by than Cupenmo Munn 1 Code,Chapter,9.13.and the Health and Safety
Code,senron 2ss32W? All roofs shall be inspected prior to any roofing material being installed.
El Ycs Na
Wtlltbcapplleo"Cofmure Wsf goccupamusecyvlPmcmor @nccawhrtb If a roof is installed without first obtaining an inspection,I agree to remove
m huzardnus or C.Outo moue a mcd by the Bay Area Air Quality Management all new materials for inspection.
Wssr{ct?
❑YCS Nu
I have read Me haranhms imu naBreyoremcnu under Chatui 95.(ft Califon
nia Health&Safety Cotic,SCCUOU )5,25533 and25534.1undessund thal Wilding
does not oily have a unam, a Is my M.,nonjul m odly the occupe,1 of NC — - —
mym nu nth mess Wmc
in Issuance or.Ccn se cmpmcy. Signature of Applicant Date
,r amt
oledagent 1 De,c All roof coverings to be Class "B" or better
v