05110062 (2)]CZ
uoc
i E
nLI2
L�
ek.LL
J -C
rtOUS
OCC
Sana
PSV
_z>
Y�c
4
0 �
z
r_
CITY OF CUPERTINO
RM)
W-0BI
NTRACTQRINFO
BUILDING DIVISION PERMIT
✓.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 iENGINEER:
BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job 1
1 hereby affirm that 1 am licensed under provisions Of Chanter 9 (commencing
ED
with Section 7") of Division 3 of dm Busincu and Professions Coda, and my IicerLx u
iA
n fullrm«arwart y_
f� 7 t I
GRANNY UNIT (573' )
Licence Class Lic. N
Date Contractor - IAa.f
lal
OCT lard
ARCHITECTS DECLARATION
1.1�
I understand my plans shall he used as public records
Licensed oral
OWNER -BUILDER DECLARATION
BUILDING
IN
1 hereby .('firm that I am exempt from the Contractor's License Law for (W
hereby
®IL®
Co orcounty
following .tion.(Smdun ]IDIS,site,. and..doram Code:
RsaiRa to ,INT, impmM, fie Nur any
122834
h Permit t
prtstcommit"
priorI n e,also a sig untimed,
prior m its issued, also requires she applicant for such permit m tilt a signed s hapten t
(hat llcemclsonsCodter9
Sq. Ft. Floor Area
Valuation
of aleged Business Code) as
(commencing witpursuantmtheofDivision3theComsiness
(cache exempt r section 7000)
basis for pion.nd
Any
and yvi
that he is exempt therefrom and dre baso for the alleged exemption. Any violation of
is
'
AW WMb(cr
Occupancy Type
P y YP
Secdon 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of
not more Nlive hundred dollar (15 L
1, owner o pramny, or employees with wage u their cele
Required Inspections
ithe
W. Buetion,
will o a retinkndedmaRe Business
duwodt and Ne is
of
law ams not apply lf an owner of
Pr obu code: The t not apply in
and ice Coed
ves the on, rad who
enywhobisillsarimproveschimp and who docsinchwork bimaelredthrough his
property
Own arortered forsake. If,
owneer.On,
is mid within one year of completion, pwmr-
Wiprovidedtha(mchimPmwmenuarene year of
builder. . Ne building or den
or proem
purpose
builder will have me burden of proving that W did not build ar improve for puryose of
sok.).
❑ 1, as owner of the property. am exclusivdy contracting with licensed comommo a 1.
construct the project (Sec. 7614, Business and Professions Cade:) The Contranm'S LI.
come law dors not apply US an owner Of PmpertYwho Wilds Or Improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Convenor's
Liecnse Law.
lam escmpt under Sec. . Big P C for this reamn
ncr Dau
WORKER'S COMPENSATION DECLARATION
1 hereby airman under porosity of perjury one of the following declarations:
I haw and will maintain aCanifiate of Consent On self -imam for Worker's eompen.
tabor, as provided for by Section 3]00 of the Labor Code. for thee performance of me
work for which this permit is issued.
❑ 1 have and will maintain Warkets Comperwrion Imuamm. as required by Section
37W of the labor Code, for the performance of the work for which this permit is issued.
My Worker's Compemadan Insurance carrier and Policy number art:
Carrier. S —RaI'6 nr'ala••V Polity No.: I O ZOS i
CERTIFICATE OF HEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This Section need not W canpleted if (W permit is intone hundred dollars (SIM)
or loss.)
I certify than in the performemc of me work for which this permit is Stood, I shall in.
employ any person in my manner an w to become subject to the WOATIS Compensation
Laws of Califmmia. Dau
Applicant
NOTICE TO APPLICANT: If, after making this Cenificate of Exemption. you should
become subject in the Worker's Compensation previsions of she Labor Code, you must
foMwith comply with Such pmvii ken m this permit shall W dmmW revoked.
i
CONSTRUCTION LENDING AGENCY
1 W teby affirm that mere is a construction lending agency for live FoKormmem of
'
the work for which this permit Is issued (Sec. 3097, Civ, C.)
Lender'. Name
Lender's Address
I certify that I have mad this application and state that the above infaam W un is
wrest I agree he comply with all city and county ordinamxs and Bute laws miming to
Wilding canmausion, and hereby auddrim repremnutives Of this city 10 enter upon She
above-menslonoul property "cut on purposes.
(We) agree ton , mdc ify and keep to the City Of Curti
peno against
liabilida,judgmenu, van spe"••which y any way am= against Said City
inconsequence of of this
'
grant permit.
ANT DER NDS NO W PLY WITH ALL NO POINT
SO
SODER S.
by: Date 2
,�1
Re-roo fs
Signake of ppli D
HAZAROUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store orhandle haandous malcrial
m defined by the Cupertino Municipal Code. Chapter 9.13, and the Hcallh and Safety
ale. Sidon 255334)]
C Ya
All roofs shall be inspected prior to any roofing material being installed.
101.
Will mea secant or future Within oma and trm
pp g P equipment 0r Twin•. which
If a roof is installed without first obtainingan inspection, I agree to remove
P
mit hvardnus air contaminants as defined by to Bay Area Air Quality Management
all new materials for inspection.
P
Diadcn
❑res u
oUuirements Wpkr6.95.(ImCalifm-
I heve mad the hm�Lm�L5.'233xrd
nuHalmkSafctyCOde.'e35 .1ndersund Wt ifthe Wilding
does nor cum Thaw a "u myyy respo bili m notify (W occupant of the
myviremcnL ichm mi.�Gancc , 'Eatearaap.yy.
Signature of Applicant Date
L / a
All roof coverings to be Class "B" or better i
Owner or millifin,mil agent Dote