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01090091 (2) CIBUILDING DVSIONO IINPERMIT CONTRACTOR INFORMATION: BUILDINGADDRESS: PERMIT NO. 22630 SAN JUAN RD EDWARD FOCHTMAN 01090091 OWNER'S NAME: APPLICATION SUB DATE EDWARD FOCHTMAN 09/20/2001 PHONE: SANITARY NO. CONTROL NO. laO O ARCHITECFIFNGINEER: BUILDING PERMIT INFO — BLDO ELECT PLUMB MECH �N' m z LICENSED CONTRACTOR'S DECLARATION Job Description t,—C eherebyalum Division 1nm licensed under provisions ofCWpar. (commencing rntm is on 7WO) on3ofthcBuxincssandPmfcssionsCodc.aMmyliccnu REROOF. 2xx� ixmranrnrceande$l. SHAKE TO COMP. a m License Class Lic.M 'Oar! DaleContractor i 3 tl G ARCHITECT'S DECLARATION .u D aJ 1 undertland my plans shall be used ax public recoNs i L ca o Licensed Pmfeesional n o Oat I am exempt from DECLARATION L= I hereby aRrm thin 1 em exempt from the Contractor's License Law for the t t i a followwhich ra reason.(Seaton 7031.5.Busite_.rood Professions Code:Any city st county aux❑ which requires a permit to c i..lin t,aha,improve,demolish,or repair any amsnaa .rWa Ilcofthesuch 's Licessi e(Cbater9 S Ft Floor - _— i3m prionoits isunnce.also aquirn pp peami gn IIWl he is�licb;wi poisuanlm the provisions of the Contractor's License Law(Chapler9 ACea,: alua[ion (commnacing wrh$mlon rim)or Division 3 of the Business end Professions Code) f_f F"s. i It ;xq'3 k)rix t, '�.•b:..: or Nal he is exempt any repro and the basis farthealleged eiduum to Any violation of not mo a than iv any applicant fore permit subjects the epplicanno a civil pmilry, 3421 of not more man five hundred annart 01500). Number Occupancy Type 01.as owner ofthe property.or my employees with wages es their sole compensation. — FIR will do the work,and the swaum is not intended or offered for sale Sm.7044. Business and Profession.Code:Tire Cammcmr's License law does not apply to an 307 - INSULATMguired Inspections owner of property Wha builds or improves thereon,and who does such work himself rough his own employees.provided that such improvemems are not intended or 601 - ROOF TEAR OFF 1 offmc,for sale.If,however,the building or improvement is sold within one year of 602 - ROOF PLYWOOD NAI L-' completion.the owner-builder will have the Wrdcn of proving that he did not Wild or t mprove roc pamoxe nr side.). 603 - ROOF BATTENS t )kIve'xnrofine""'pmy.amexclusively comrmdngwith license acontractors to 604 - ROOF IN-PROGRESS moswet the pmject(Sm.70W,Business and Professions Cada)The Contactor's License Law coax are apply to an owner of pmpcny who Wilds or improves thereon, and who comment for such pmjmts with a contactoos)licensed pursuam to IM1e Cnnbamm's Lim taw. Olein reef Sac c/ ,B&PC for this mason Ow '' Date / YC U WORKE 'S COh1PENATION R crchy uRrm under penalty of perjury one of the following declarations: 777�'ttt ❑ 1 base and will maintain a Cmificate of Consent�o staff insum fm Worker's Compenuthm, as provided for by Section 3700 of the, Labor Code, for do performmtce of rhe work for which this pcmcl is caused. ❑1 have land will maimnin Workers Compensation Insurance,as required by Section 37W of the Labor Code.for the performance of me work for which this permit is — � issued.MY Worker's Compensation Insurvrce artier erd Polity number ares ,_,._ ._„ ,. _ Carrier, •GERTIFIGA L. ..Policy No.: x '{, o-' s+f.y. f'sxw' x'' ,1, { 1'ri •4 x. ; ^TION OF E%EMPIION FROMWORKER$';, "•' ' n•'u- ,\ 4 1 ',.iaS.'v.i tE�.4. - COMPENSATION INSURANCE' - .... . . _ .___.. . . ..._..__, ... t _ _ ... lite s union meJ nw be complaed if du pemdt is fm ooa hundre0 dollen - x" ''' (SI00)or lcnJ , ' 1 cmifY that in he performance of the work for which this permit is issued.I shill not employ any pcnon'in any partner u as to become subject to the Wake. Compensation laws of Celifomie.Dale Applicant NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should bacome subject o the Worker's Compen cation pruvis ons of the Labor Code,you muss O foMwith comply with such provisions or this permit shall be deemed revoked. Z1 - . ICONSTRUCTION LENDING AGENCY a 71 limby aff rot that thea is v construction leading agency for the performano, (s7 of the work for which this permit is issued(Sec.3W7,Civ.C.) 0. Q I<ndcr'a Name _ 5 Z Lenders Address ,. I unify Ihat I have read Ihis application and uaa ordinances a above information is k. 0 to Wildiagree ng construction, mon,amply whM1all bymaand.county e,roadinanccsand state y lawyer upon O.0 mWildingcoitiona iomane M1crtbynuctionpspreumatives of this cirymenar upon F0. the abo(We). oned pmpeny for inspection purposes. ;Cn• (We)agmc m save:indemnify and keep hamdess the City of Cupertino against (n liabilities,judgmemu,costs end expcnua which.mey in any way aroma a inn said U y city in consequcn S AN61se g of this permit:MP APPLICA.Tu, )ERS AND$,,NDWILLCO or na THAL.NON OINT issued by: Date CE EG A' NS 26 6 y Sig nfAppa=a nlarr Date Re roofs HAZARDOUS MATERIALS DISCLOS RE In the applicant or T tux Wilding ac P 1 lore or handle haratdous material.. Type of Roof r` . t - . . ... .. -, _. ....._ ... d red by Nc Cupen ft(imaypal Cade Cn pt 9 12 and the HcaIN ertd Sefcry •t., C a.Sabon 25533(x) ] I 1•f1 ❑ye,., Ne, _All roofs.shall be inspected.prior.[o any.roofing material being installed. Will the applicant or mature Wildingocmin,al uueyuipmem or devices which If a roof is installed'without first obtaining an inspection; I agree to'remove ,,it Wrojohms air cnnammams darned by the Bay Area Air Quality Management District all new materials for inspection. Applicant understands and will comply with oyes Nn all non-point source regulations. Prhave rcad'Ihe hexmdous rtW ids 505.2 533a Ender' 4.1 un 695 of the Celiromie Health&S t cry Cod e r s 35505,t it and 2553a.I understand that if the Wilding does vin c Y have v t uthm it is my responsibility m notif the are.'ra of the memkwhich m drop,issuance of a enifi a of `y Signature of Applicant Date Zo 6 = O.mn miecil cm, .. - le All roof coverings to be Class "B"or better . OFFICE '-