05090151 CITY OF -CUPERTINO - � ' R7 r�zr'?,�-z^
BUILDI NG DIVISION PERMIT cONTRaCTORINFORMATION'
BUILDING ADDRESS: PERMIT NO.05090151 SO9O151
6
.R'S NAME: PERMIT ISSUE DATE
ERAN COHEN
E:
SANITARY NO. CONTROL NO,
ARCHITECTIENGWEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
0 0 0 0
:oo LICENSED CONTRACTOR'S DECLARATION Job Description
�wC I thereby affirm Nat 1 am licensed under pmvisirm of Chapter 9(commencing P
z- with Seefim70M)of Division 3 of lie Butioness and Proressium Code.and my hear.is
.aF infull romeand errea REVISION--ELIMINATING ENTRY/GARAGE,
j igi License Class Llc,a
mm Cant.mar WATERPROOFING BALCONY
ARCHITECTS x TS DE CURATION NO NEW PERMIT ISSUED/ORIG. #05060001
rya 1 undersand my plans shill be used as public recards DECLARATION
le.
s 4�; Licensed Professional
5 OWNER-BUILDER DECLARATION
I 1 hereby affirm that I am exempt from the Contractors License Law for the
i.e O following lesson.(Section 703 1.3,Business and Professions Code:Any city err coumy
which require a Permit to emooma,eller,improm,demrlL h,in,repair any structs.
prior m its issuance.also requites the applicant for such permit to rile a signed statement
Zi 'no heis licensed pinummatroNepmvWomofthe Conuxmr'sLianc, aw(Chepter9 Sq.Ft. Floor Area Valuation
Y~$ (commencing with Section 7000)of Division 3 of the Busirteasand Professiam Code)or [•66240
that he u exempt therefrom and the b lis for the alleged exemption.Any violati $
on or
Section 7031.5 by any appliesem far a permit subjects the applicant Ina civil penalty of APN Number Occupancy Type
ma..thannvahandleddelta.($5w). Pane Y YP
I,as owner of the property,or my amploycu with wage as Chir sale compensation,
will do the work,and the swaum is not intended mattered tomb(See.7004,Business
and Pmfeaders Code:The Conmctars License Law does trot apply in an..of Required Inspections
pmpeny who builds or improves Herron,and who does such work himself or through his
own employ=.provided thmsuch impmaemenes arc not intended maimed for We.If. �s
ho ldtie the aw,ting ar impmwment is sold within am year of uni nl.for the ownery �/
builder will nave tic Burda eof,pmmi i Nat he did at build m improv,for thepurpece,rat of
a4.).
I.as owner of the prop,ny,am exdaiv,ly contracting with licensed contractors w
me La dre Miss
t (Seco an Business and Professions Code:)The ns themon,Lid l j
cense law docs nm applyja an owner or progeny who seWilds or improves thereon,and
who contracts for such projects with a conuacmr(s)licensed Pursuant to dre Contractors
License law. J
InexemptunderSec. .B&PC(orNum•.^n
r � Data /a S fWORKER'S COMPENSAnON DECLARATION
1 hereby affirm under penalty of perjury ane of Ne following declarations:
sw and will maintain a Ce tifian,of Consent to sel6Nsum for WorkersCompen-
rifor which Nis permit is issued.
ave and will maintain Wmkui Compewtion Issuance,as required by Section
of the labor Code,for Ne performance of Ne work for which Nis permit is issued.
orker's Compensation Insurance carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thessecdon need notbeeomplered Irthe permit iarurmtehundred dollars(SIM)
to less.)
I certify that in Ne p,rfivmane,of the work for which this Permit is issued.I shall not
employ any person in any in r ecomasubj,cuo the Workers'Compensation
Laws of Califomia
NOTICE
NOTICE TO APPLICANT.If.after Compensation
omm sari Nis Genion of of Faemptio d you should
become scomp y the Waherro Comp or this em iit ions of the meedLinvu CMe,you muse
.Jz Forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
(•" I hereby tlTum Wt Nem iso emiummum lending agency for th,Performance of
Q$ Nc work for which his permit is issued(Sec.3097,Cr,C.)
dLanders Name
a z Landers Address
U O 1 cenify that 1 have rad lids application and sate that the shove information is
14
Comm 1 agree to comply with all city and county ordinances and suite laws minting to
�U building construction.and hereby authorize this of this city to enter upon the
r W Aleve-mentionnd property fm inspection purposes
t••�LL (We)agree w aave,indemnify and keep harmless the City of Cuparne.against
fA liabilida.judgmcnts,easts andexpemu which may in any way accrue against WdCity
U z in conaequen a of the granting of this Permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: du
Dale
SOURCE REGULATIONS. —
srgmm�re or bcanVCanmc1or /Y�f' Re-roofs d-
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will We applicant err ferule building oaupam nom or handl,luardoue,materisl
ended by Nc Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
.Section 25532(.)?
❑r a K1 No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or ffuutture building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
chat hazardous air conuminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
Distriet?
❑Yes �Nti
1 have mad the haad,ms materials requirements under Chapter 6.95 althe Califor-
niaHalth&Safety Cade,Sections 25505.25533 and 2553x.l understand dtatifthe building
deo not curmndy hoc•renana that it u my responsibility in notify the ae.roat of dte
rcyuilemcnkxwhichmusibc I 'oI isstanceor.cerde.w.fCacupan Signature of Applicant Date
owner r autharim0 agent g
All roof coverings to be Class 'B"or better
taDare