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