04060235 CITY OF CUPERTINO .. ' try ` "' - -
'BUILDING DIVISION PERMIT - - xotVT WITORM01 """'�'T1N
.k' .i. Vc
BDILDINGADDRESS: _ EDWARD FOCHTMAN PERMIT"04060235
22630 SAN JUAN RE)
+NEWS NAME: PERMIT1SSUEDATE
EDWARD FOCHTMAN SANITARY NO.
E: CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
yOp LICENSED CONTRACTOR'S DECLARATION "
1 hereby affirm that l am licenced under provisions of Chapter 9(commencing Job Description
with Section 70fB)aDivision 3 of the Bouisemand Professf...Code,and my license is
in full tome and affect. REVISION--FOUNDATION/WALL
pq? License Class Lie.#
Z�, Dam comracmr $NO NEW PERMIT ISSUED/ ORIG. 03070166
WARCHDECT'S DECLARATION
1 I understand my plans shall he used as public mcords
Dye
3 ta LicenMd Professional
GSOWNER-BUILDER DECLARATION <0 \
9y I torch,affirm Ihot 1 am exempt from the Convector's Lianm Law for the Q
i OD fallowing mann.(Section 703 1.5,Business and Professions Code:Any city or county S
$� which notaries a permit m c.nswtr,elle,improve,demelksh,ar repair any immure,
F to prior m its issuance.also Inquires the applicant for such permit to rile a signed statement'
q that he is licensed pamounuaaheprovisions ofdmContmcmr'sLicense law(Chapter 9 Sq.Ft.Floor Area Valuatio, 107
jHg (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i that he is esempn therefrom and the burs for the alleged csempuon.Any viobtton of
Scott=7031.5 by any applicant for a permit subjects me applicant to a civil penally of APN Number Occupancy Type
not mon man five hundred dollen(5300).
❑I,uownuoflhepmpeny,ormyemploymswWweguumeirsolceampensalion, 34218004 . 00
will do the work and theMmnure is not intended oronered furaale(Sec.7004,Business _
and Professions Code:The Convenor's License law dots not apply to an owner of Required Inspections
property who builds or im proves thereon,and who dao such work himself or Otrough his
own employees,provided that such improvements art notimmnded muffered Russia.IL
however,me building or improvement is mid within mm year of compleuon.the owner. -
builder will have me burden of proving that M did not build at Improve for purpose of
safe.).
❑I.as owner of the property,am"elusively convecting with licensed contractors to
construct the project(Sec.7044,Business and Profusions Code:)The Conbecmr's Li-
cense law dean not apply to an owner of property who builds or imprevu duccon,and,
who convacu for such projects with it co.vacmr(s)licensed pursuant to the Contractor's
LipQQpQQenM Law: -
6�umptuntlerSec. .BR PC for m1`
w
n
Owner
RKE COMPENSATION DECLARA
I hem y a rte under paaity of perjury one of to following declarations:
haven ill maintain a Cerdfeae of Causes m self-inure for Workers Compere
sation,an provided for by Section 37011 of me labor Code,for me performance of the .
work for which this permfl is issued.
❑I have and will maimain Worker.Compensation Insurance,as required by Section
3700af me Labor Code,for to performance ofthe work forwhich this permit is issued.
My Worker's Compensation Inme nce carrier and Policy number are:
Carrier. Policy No.: +
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCEi
(This section need net Wcompleted If the permit is for one hundred dollam(510)
or loss.)
1 certify than in the performance of me work for which this permit is issued,l shall not
employ any perm.in any manner,m as m become subject no the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Contrition of Eacmpnion,you should
become subject m the Worker's Compensation previsions of the labor Code,you most
.J O forthwith comply with such previsions or his permit shall ba deemed revoked.
.Zi tiCONSTRUCTION LENDING AGENCY
'Tr I hemhy sTum mat mem iso construction lendingagency for the perf.wo.two of
6ai 7 the work for which this permit is issued(Sao.3097,Civ,C.)
GQ Lenders None
z Lender's Address
V I aniry met I have and this application and sum that he above information is
C[.H cormcl.I agree to amply with all city and county ordinances and state laws relating to
p V building cunswction,and hereby authorise npremnutivas of this city in enter upon the
W slave-mentioned pmperty for inspection proposes.
got (We)agree ro save,indemnify and keep harrom,the City of C.Is nine against
izi liabilities judgments.costs and expenses which may in any way seem,against Mid City
U^
PLICANT DERrsnutagANDS AN WILL COMPLY WITH ALL NON- 01 Issued by: Da
SOURC E13 AT N
L O Re-roofs
nemm pPlicanUComrscmr am
HAZARDOUS MATERIALS DISCLOSUi Type of Roof
Ailc applicant or future building^ccupml store or hmWlc himallous material
as def e y the Cupertino Municipal de.Chapter 9.12.and the Health and Safety
Code, don 25532(x)?. All roofs shall be inspected prior to any roofing material being installed.
❑Ye o
Will the applicant or future hold occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Weardoua air contaminants as recd by the Bay Arc.Air Quality Management all new materials f n.
tarn?
Pres o
I have mad the baa le ids requircmcnu under Chapter 6.95 of the Califon
nice Halm ASefclyC .Sections NI5,25533 and 25534.1 understand met'do ildin
dans not cuncnn ase a sena th it fs my mMonsibiliry m notify the_cap
of / �' 0
rcyuiremc i' most n r uanccofaCcniOcamafQcu cot Sign Of pplicant Da
Z U
rigcdagcnf m All roof coverings to be Class"B"or atter