04100159CITY OF CUPERTINO'.(gg°j.s,g^a
.•: BUILDING DIVISION-'PERNIIT'-�.#:..I
BUILDING ADDRESS:- . -
HALLMARK CONSTRUCTION INC
PERMIT NO.
04100159
OWNER'S NAME:.
PERMIT ISSUE DATE
E.
SANITARY OL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description - -
P
1 hereby affirm that 1 am licensed under previsions of Chapter 9 (commencing
.hh9 it. OW)of Diviaiorilof Ne-011 sand PmfessiosiCem.andmylicenmis11
'.
Liais. Im "` Lkx13 3 z-13
REVISION--TRUSS DEFERRED
NO NEW PERMIT ISSUED/ ORIG. 404070197
[Dam ConARCHITECTS Dr'F"e` TDN
v I umdc.mm my plain shall o used as A m records
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Licensed Professional
' OWNER-BUILDER DECLARATION
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1 hereby affirm Nat 1 em exempt from the Contme or's License Law for the
following mason. (Section TIB 1.5, Business and Promwskes, Cade: Any city or county
which requires a Permit to construct, alter, improve, demolish. or repair any someone
prior to its issuance, also requires the applicant for such permit m Ole a signed smmment
he is licensed to of Connectors U.. Law (chapter 9
Sq. Ft. Floor Area,
-- Valuation
that pursuant the provisions the
$36
(commencing with Section 7000) of Division 3 of me Business and Profusions Code) at
that he is exempt themfrom and the beau for the alleged exemption. Any violation of
APN Number -
Occupancy Type
Section 1031.5 by airy applicant for a permit subjects me applicant to a civil Penalty of
not more man flue hundred doll. ($500).
❑,1, es awnm of the proprny, ar my employcu with waguutheir sole compensation,
32632
will do the work, and the suucture isnotimmnded proffered fonale(Sese.7W. Busentes
Inspections
LawRequired
The Commutes.. License ams not apply to an owner of
andporty.ho
.
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dmasWhwded creamed hmugh his
whaoildaortmpmvuth oes
WHO.,
s, such improvndwho
owncro arist for. .IL
ownemplRan
wire uminstaurrroRem,
Wilding or i po.improv to within ane year of completion,theowner-
houider, Nebue order
builder will have the burden of proving that he did not build or improve for purpose of
ft of pmentiahat
sale.).
C ��
❑ I. as owner of the progeny, am exclusively contracting with licensed contracts. to
construct the project (See. 7044, Business and Profrseions Code:) The Cont.cmr's Li-
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terse law dose not apply to an owner of property who Wilds or improves thereon, and
`
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whoconsectsforsuchprojectswithaconimentr(+J licemod pursuant in ft Contractors
-
License Law.
❑ Iamexemptunder See. ,B&PCmrmismmW
Owner Data
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- WORKER'S COMPENSATIONDECLARATION
I hereby NTnn under Penalty of perjury one of dm following declarations:
have and will maintain a Ccrificate of Carton to self-imure for Workers Compere-
- -
sadon, ea provided for by Section 3700 of the Labor Code, for me performance of me-
work for which this pamtlt Is Issued.
❑ I have and will maintain Worker's Compensation Insusvtm, u required by Section
37W of me Labor Code, for the performance of the work forwhich this permit is issued.
'
My Workers Campemmlan ouranm carrier and Policy number a2:
careI 3T/1ReFiii boli p.: '113—CYOROa�'
CERTIFICATEOFEKEMt` RROMWORKE S'
COMPENSATION R7SURANCE t0`)l(xr
(Thumctirnrmednalocomplemdlftheparmilisforanchundre1ddolla.(SIMI
or loss)
,
1 ecAfy that in me performance of the work for which Of, Permit is ismad. I shell not
Cmploy any person In any manner an as in lV.Yame aubjeel to me WorkmaCompensation
Laws of Calimmum. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject be the Worker's Compcuation previsions of the Labor Code, you must
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forthwith comply with such provisions or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby aRno mat mere is a casswctimn lending egenry for Jin performance of
the work for which this permit is issued (Sec. 3097, Cu, C.) "
Leaders Name
Landers Address
I certify mat I have mad this application and smm that the mors information is
co met. I agree to comply with all city ad county ordinances and sok laws misting to
building construction, and hereby authorise mpmxnatives of this city to enter upon me
move-mentioned progeny for iormedon purposes.
(We) agree to save, indemnify and keep harmless to City of Cupcnino against
liabilides,judgments, costs and expenses which may in any way ameme agaiut mid City
in cmarquenee of me gaming of this
,� r� -
Permit.
APPLICANT UNDERS AND AND WILL COMPLY WITH ALL NON-POINT
Issued by: ate
SOU GULA S.
Re-roofs
1 1 a� It
atu f pp is N Paamr C me
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will On applicant or future building occupant store or handle hasammus material
u darned by the Cupertino Municipal Code, Chapter 9.13, and the Health and Safety
Code. Section 2553200?
❑Yoe �dNa
All roofs shall be inspected prior to an roofing material beim Installed.
P P Y g g
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or Future building Wcupanl um equipment ar devices which
I hmandous air contaminants ss defined by the Bay Area Air Quality Management
all new materials for inspection.
.Viet?
Yes JtNu
I have mad the haaardms mamrials requirements underChapmr 6.95 of the Califon.
od" SifeyCedc, Sections25505,25533 and 25534, 1 unde.mnd that ifthe Wilding
L_�W]E]
rmrcurrcndyhave nant,titismymaponsibilitymnotifymemcupmtofthe
amt which IsmanmaracenircawnfOccupanSignature
ofApplicant Date
kJA tO
All roof coverings to be Class "B" or better
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araumt,67.adagent to