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06020148 (2) CITY OF CUPERTINO ` � , BUILDING DIVISION PERMIT � CONThXC,OR INFORMA'�ION.'-, : BUILDING ADDRESS: PERMIT NO. 06020148 ov&&5gnidE:N PORTAL AV PERMIT ISSUE DATE mew 'IAWARi CHESSEN SANITARY NQ LNo. ARCHITEC(ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MFCH ip LICENSED CONTRACTOR'S DECLARATION i� 1 thereby affirm that I em licensed under provisions of Chapter 9(commencing Job Description e� with Section 7")of Division 3 of NC Business and Profcasions Code,and my license is in full force dad effect v 1- ucenrecl Lk.ayZ7 REVISION--ROOF GABLE TO 6 ' Dam Comnctur ARCHITECT'S DECLARATION RDUCE SETBACK ?� lundcrsta Jmy plans shell he uutl es public rceorde NO NEW PERMIT ISSUED/ORIG. #05110062 'u it; Licensed Professional g OWNER BUILDER DECLARATION I hcrchy affirm Nat I am exempt from Ne Comnmor's License Law for the i O following reason(Section 71131.3.Business and Professions Code:Any city Of county es 3 which requira permit to Constru0.alma,improve,dcmoli h,or epan any structure y prim in its issuance,also requires the applicant forsuch permit to Ole a signed statement Cp that he is licensed pursuant to the provisions of the ComncroriLicense UW(Chapter 9 Sq.FL Floor Area Valuation (commencing with Section 7000)of Division 3 of the Business and Professions Cox)or $ that K I,exempt therefrom and the basis for she alleged Gumption.My violation of Section 7031.5 by any applicant for a permit subjects the applicant to a twil Penalty of APN Number Occupancy Typ not mart than foe hundred dollen($500). ❑1,as owner of the proputy.or my employees with wages as their able compenadon, will do the work and thc&=lure is not intended of offered(mark(Sec.]Dai,Busirrss and Prefeemns Cox:The Conuaemrs Lies.Law does not apply to an owner of 316 3 0 0 9 7 . 0 0 Req a Inspctions progeny who buildsor improves thereon,and who does such work himself orthrough his �� own employees,provided Nat such improvements are not intended oroffered toraal.If, howeref.Ne building of improvement is old within one yeti of completion.Ne mvucr- Wilder will have the burden of proving Nn be did not Wild or improve for purpose of ark.). ❑T.as owrcr of the ec.7progeny..m sine siv and contracting with:)The Coonhantnrs i- comwcwk pone t (Sec.opal,Business.rod ny who Code:)The Contnmur'a Li- . wholaw cars not man owner of peopeny who Wilds of improve thereon,and woo comncm for sato projects with a comracmr(a)licensed pursuant In the Contnetote LicI am Law. ❑lam exempt under Sec. ,B k P C for this moon Owner Data WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of rhe following decWatimas: ❑1 han and will maintain a Certificate of Consent o self-insure for Worker's Compen- sation,as provided for by Section 37W of the tabor Code,for Be performance of the work for which Nis permit is issued. 1 have and will maintain Workers ComKmfion Insurance,at required by Section 3700 of the Leber Cod,for the performance of the work for which this permit is issued. My Worker's C..,.donY�pssenna certief and Policy nurrOW,see: Gmicr: Tea. T `^� Poliry No.: 187,6 Sf g CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE . (this section recd not Mcomplcmd Bthe Permit is for am hundred dollars(SIM) of less) I cenify Out in the performance of the work for which this permit is issued,I shall not employ any person in any mann,so as Or b eme.subject o Be Workeri Compensadon Laws of Califxent.Data Applicant NOTICE TO APPLICANT:If,aper making this Cenifcam of Exemption,you should become subject in the Worker's Compensation provisions of the labor Code,you most O foMwit comply with such provisions Of this permit shall x dcemed rewkcd. Vy CONSTRUCTION LENDING AGENCY I hereby affirm that there is a cons0uctinn lending agency for the Performance of Ne work for which this permit is issued(Sm.3097,Civ.C.) QLcndces Name, z Lrndcrs Address Q 1 cenify Nat I have read this application and We that the above information is E' CmeeL 1 agree to comply wit all city and county ordinances and sum laws elating in V building eonsuuction.and hereby auNo' represenutins of Ni'c city mentis upon tic L17 aMve-mcmioned progeny for,insZ,--d c on ugwses. G (We,)agree to pve,inx ify d kcep humless the Ciry of Cupcnino.gaitex N liebilitiu.luddmcnts.costs an ape swh'RhaLy,,.,xCC..,aJ.ts&idCi1, APPLTAIWof DERM N of AND ILPC PY WITH ALL NON-POINT SOURCE RE U TI Issued by: Date —/7 SCJ Z Signature OfApp&UrIixmactCr Re-roofs HAZARDOUS MATERIALS DISCLOSURE Data Type of Roof Will thc applicant of future building nccuPamnore or handle havardous m.urial as definud by the Cupertino Municipal Code,Chapter 9.12,and the Death and Safety Code,Sc Non 25532(x)? ED Yet 3+< All roofs shall be inspected prior to any roofing material being installed. Will thea ream nr future building Attu ant Use If a roof is installed without first obtainingan inspection,I agree to remove PP g P cyuipmem or dcvims which P e.. Uisvict?cl, us air contamivnts ss defined by tree Bay Arta Air Quality Mwgcmcm all new materials for inspection. ❑Yes kl�o. I have read the hvsrdousma as uimmcm LaderChepu06.95tUfthccalifor- niaHUIN&SafctyC3gc,Secums 50. 33 rod 53d.1u nfsmnd lhu if the huilJing does not currently (.e.tenant. t it ty resp ihibty of he p,uP�of N eyniemcnts sunt vlxor nett ssuanc ref.Cc DecuE c. Signature Of Applicant Dale n ( D Owner of tuthorrrcd 9&06t D,m All roof coverings to be Class "B"or better