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 '-