05010156 CITY OF CUPERTINO •> +w *s-�g, -`+"'- >xt '
BUILDING DIVISION PERMIT CONTRACTORINF.ORMATION $.
. ; sem..
BUILDING ADDRESS: HEIDI NIUFAR PE""'05010156
ER'S NAME: PERMIT ISSUE DATE
2 7.19
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
L,Z' LICENSED CONTRACTOR'S DECLARATION Job Description
C 1 Wmby affirm Nal I am licensed urvmr provisions of Chapter 9(commencing p
fJ Ou with Section?")af Division 3a(dw Business and Pmfessions Cade.and Any license is
s rce in full foand effect.
5'qi LmerxCazs Lie.If STUCCO/CHG WINDOWS & DOORS
r•o Da¢ Cuotracwr
44 ARCHITECTS DECLARATION
1 understand my Plans shall he used u public rteortls
Dau
;ot, Lucrtscd Professional /
5 OWNER-BUILDER DECLARATION
0 f 1 hcmhy.M.(Sce that 1 A.1. ,Busies from the Cssions ors License law for the
pO followwhichingmassa(Saito 7031.5,Business and ve demolish.
or Any city or county 0
x$ which reyuitu a Permit est conswn,elmn improve,demolish.or repair my stwcture
Fibprior m its issuance,also m ires the applicant for such permilto Glc a signed statement
That he is licensed purman0o the provision of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuati
,4~3 (commencing with Section 70()M Division 3 of the Business and Profeuinn Code)or
i 5_ that M is exempt deterrent and Ile huffs for Ne alleged exemption.My violation of
Section 7031.5 by Any,applicant for a permit ubjects me applicant to a civil Penalty of 3 7. er0 0 Occupancy T
not mare man foe hundred dollars(SM). P Y Ype
❑I.uawar of the psvpaty,mmy employcu with wagesutheir role compcnution,
will do the work,and mcsuuctum is not intended oroRered forsalc(Sec.704x,Business
and Professions Code:The Contractors License law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himselfor through his
Own employees.provided mat such improvements Are notinended oroRered for sale.If.
however,the building or improvement is told within one year of completion,me owner.
builder will have the Write.of proving that W did not build.r improve for Impose of
sale.).
❑I.as mvner of the Property,am escluively contracting with licensed cuntracwm to
constmet the project(Sec.7W,Business and Profusions Code:)The Contractors Li.
cense law does not apply to an owner of progeny who Wilds or improves themon,and
who contracts for such projects win a conuntor(s)limnxd pursuant w the Contrutoes
License law.
01 Am
lam cm funder sec. .B&PCT mit reuon
21 s..S
tar}
W R'SCOMPENSAT�N DECLARATION
I hereby Affordrpenalty of perjury oncof me following declarations:
I have and will maintain a Ccmficam of Consenttoself-insum for WorkcesCompen-
satisn,AS provided for by Section 3700 of me labor Code,for the peormn anca of me
work for which this permit is issued.
❑1 have and will maintain Workers Compensation insurance,u required by Section
37W of the labra Code,for the pcdo...of Use,work for which this permit is issmd.
My Workers Compensation Insomnia carrier and Policy number am:
Cartier. Policy No.: '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not W complemet Elite Irrmit Is formic hurdfcd dollars(SIM)
or lis.)
I«niN that in the perforniaae of the work for which this permit u issued,l shall not
em any person in an manner an rite me i4pltn�tWarkcrs'Com nation
Laws of Cxlifo`nia.Di� � m` 1 f�L_
Applicant�I 1 ' �i �E C
ii
NOTICE TOA PLICA If.after making Nis CediGcem of&cmption,you should
become abject to me Worker's Compensation provisions of IW labor Code,you must
.J Z forthwith comply with such provision or this Permit shall be decmcd revoked.
ZO CONSTRUCTION LENDING AGENCY
[� Ihereby Arm that them is a construction lending agency for the Mrfurmance of
C' me work for which oris .it u issued(Sec.3097,Cih,C.)
W QIandcr' Nam
e0.
C Under's Add.
I>Q 1 1 cenee n c I have read oris application and rue Net the abort information is l /
IT, U con in 1 onab w comply with all city and county aNinan of and sum laws relating to ✓/O//
p V sinew mentioned PmKnd hembyecdorimn pur,v enuti.es of thu city in enter upon the
} aWvc.memioncdpwPcny for iexpcnies puryoxa
(, gy (Wc)agree move.indemnify and keep harmless the City of Cupertino against
N inconAUSmideorthecovtsandcapcneswhichmayinanywayaccrueagainstuiOCiq
V z in consequence of the granting mf oris permit. /
APPLICANT UNDERSTANDS AN WIIL COMPLY WITH ALL FONPOIM Issued by: Date
\ SOURCE REGULATIONS Re-roofs
s Zf(�
Sign �e ofA pli- UConoaam Da¢
,HAZARDOUS MATERIALS DIy CLOSURE Type of Roof
Will the Iicant or for=Wilding occupant store orliaMlc hvndous material
u deftud by the Cupertino Municipal Code.CRapmr 9J22.and the Healdt and Safety
c.Section 25532(a)?
Oyes ON. All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant of future building oat est t�a If a roof is installed without first obtaining an inspection,I agree to.remove
pp 6 W yuipmcm or devices which g
emit haamrus air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. .
District?
❑Yes ON.
I have mad the haaNnusmaterials requirements under Chap,r6.95 of the Califon
ria Health&SafetyCode,Sections 255(15.8533 and 25534.1 understand matifthe building
does not currently have a mnant,rtllary � my wapm h,llty w notify IM OmupNl Of the
myuiremcnts which mustbomet arm uancc (a Ccnifca of Oc ucmr0 Signature of Applicant Date
_.I n �0L I
owne'r atm .<d sent I Dar, All roof coverings to be Class"B"or better
U