05110062 CITY OF CUPERTINO
BUILDING DIVISION PERMIT NTRACTQRINFO
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RM) ON. -
✓.30 e
BUILDING ADDRESS: PERMIT N0.0 5110 0 6 2
10571 N PORTAL AV
NER'S NAME: PERMIT ISSUE DATE
STAWART CHESSEN 6
NE: SANITARY NO. CONTROL NO.
ARCHIEC (ENGINEER: BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
u0, LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job 1
with Section 7000)of that
3 of the Busineu and Professions Code,and my license h
inrmlro«anaert yy_� A ED
GRANNY UNIT (573 ' )
3 Lici in Clus Lic.g � �/L 7 t l
n9a Dam Contractor - IAa.f OCT 4 o 2U�ri
qqty ARCHITECT'S DECLARATION
C i I understand my plans shall W used as public records U L
II e
g G Licensed Professional
3 OWNER-BUILDER DECLARATION
1 hereby.('firm that I am exempt from the Contrmmfs Licence Law for the IL
tpo followingo:m,a.(Section]IDIS,"site, and Pre.dernru cattle:Any city at county
m which requires n permit r1.e annaw0.nicer,improm,demolish.fi repair any s.ucmre 122834
yz< that he itsIssuance,parroutquite the applicant for suchPermitrefiled signed hapiort
yam$< that cingwidpurction7 Ncpmvivioion3or Contranessalcemclaw(Chaptr9 Sq. Ft. Floor Area Valuation
(cat he is ixemiNSecuon]OW)of basis
the
theeged Business pion.nd Any
Cddle)on or
that he is exempt therefrom and the baso for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant W a civil penalty of AVX WMblicr Occupancy Type
mot m
nom Nan Eve hundred dollen(15 L P Y YP
1,o owacr o lthe propene,or is employees with wage u their sole W.Buauon,
will Pr the,work.end indictment.Com u rant intended m aRe dos not.(Sec.]OCG,Butlnev
dna property
who Ina code:The Commences rad who law dans not apply lf rt owner of Required Inspections
pmpeny who bu lids ar improves thereon,and who dons auch work bimselr or through his
Own employers,provided that
pnovarimPmmmenuarenos intendedarofferodmpletin.forstaJthe man If,
builder ..the building or improvement is mid within one year or complcdon,purpose
pose of
builder will have the burden of proving that W did not build ar improv for purpose of
sok.).
❑1,as owner of the property.on exclusively contracting with licensed compactors rep
construct the project(Sec.7644,Business and Professions Code:)The Conuanm's Li.
cone law don not apply to an owner of propenYwho Wilds or improves tW mon,and
who contracts for such prejeets with a con ractor(s)licensed pursuant to the Conrramor's
License Law.
lam escmpt under Sec. .B&P C fm this mxmn
ncr Dat
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under porosity of perjury ane of the following deehmtiuns:
I haw and will maintain aCenifiat of Corucnt W self-amre for Wod efs eompen.
sation,as provided for by Section 3]00 of the Labor Code.for tW perfarmance of the
work for which this permi(is issued.
0 1 have and will maintain Worker's Compensation Insurance.as required by Section
"I of the Libre Code.for the perfarmanee of the work fm which this permit is issued.
My'
y Worker's Compensation Ilnssu'raa�ncee�carrier and Policy number art:
Carrier.S9'gaV1"6 rr'ala••V Polity No.: g O ZOS;
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ITh section need not W eampleea if(W permit is fortune hundred dollars(SIM)
of loss.)
I certify that in the performance of the.,it for which this permit is issued,I shall nm
employ any person in my manner an as In become subject to the WOATM Compensation
Laws of California.Dat
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.You should
become subject W the Worker's Compensation previsions of she Labor Civic,you must
.JO forthwith COOONY with such Innovation m this permit shall W deemW revoked.
'Z..' CONSTRUCTION LENDING AGENCY
'reqI Wmby affirm that there is a construction lending agency for de ,an
perfmmce of
ce r7 the work for which this permit is issued(Sec.3097,Civ,C.)
W Lender's Name
=z lender's Address
V Q 1 certify that I have mad this application and sot that the above inform W un is
W F^ com eL I agra to comply with all city and county ordinances and sot laws misting W
OU Wconstruction.building coction.and hereby auddrine representatives of this city 10 enter Open the
ahovemcmionoa property f cuon purposes.
(We)agree tom ,mdc ify and keep le the City of Cupertino against
r fA lubRitia,judgmcn0. uan xpmCsaawhich yi my wayaccmcsgainst said City
C)7 in conmqucncc of grant of Wis permit.
T'r APPLI ANT DER NDS ND W �1PLY WITH ALL NO POINT Issued by: Date2 i� ��
SODER S. ,�1
lll��� or l/ Z:y a6 Re-roofs
Sign a of ppli HAZARDOUS MATERIALS DISCLOSURE D Type of Roof
Will Ne applicant or future building occupant store orhandle haoseeous metrial
as defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
I
le.Section 25533(a)? All roofs shall be inspected prior to any roofing material being installed.
Yea
Will the a secant at mare Wilding area ant use If a roof is installed without first obtainingan inspection,I agree to remove
PP g P equipment or devices whit!, P
t havardous air contaminants n defined by the Bay Area Air Quality Management all new materials for inspection.
P❑YaI have maJ Nchmallousryr� srequiremnts hapkr6.95ofthe Glifor-
HaIN&SafctyCude.Sec'eRs r5,3557J and 35 I nMrsuM Wtifthe Wilding
s not curren flow a ante y1(h in3,L respo bili W notify Be occupant of the
uiter ichor W ( or lala2ff a Met Signature Signature of Applicant Date
H! f// L/ a
Owner or..Irlaed agent DOW All roof coverings to be Class"B"or better ri