05020070 C1TY OF CUPER'I'INO t'tzn ✓ ' a 'c:�' ,« ` �� x'
BUILDING DIVISIONpF C�0NTYtACTnRA FORIM�ON
BUILDING ADDRESS: HEIDI NIUFAR PERMIT NOO 5020070
ER'S NAME: PERMIT ISSUE DATE
18791 ARATA WAY
PHONE: SANITARY NO. I n,l 2 CONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
�Oo LICENSED CONTRACTOR'S DECLARATION
sup 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
!tw with Section 7")of Division 3 of the Business nd Professions Code,andmy license is
n<u in full force and effect.
`n tj License Cly Lie.a INTER STRUCTURAL REENFORCEMENT
ZFc Dam Contacmr TERMI E R
dd�� WLED
ARCHITECTS DECLARATION
Yat I understand my plans shall bet used as public records START J0I3 WITHOUT' PERMIT/BPERMFEE DOUBLED ($410
0t Licensed Proe
fessional '"'U 2005
g OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt form the Contractor's License Law for the
00 following reason.(Section](131.5,Business and Professions Code:Any city or county
m[a which intones a permit m enhance. he,.improve,demolish.or repair any sound.
Fie poorto itsissuance,also requires the applicant for such permit to file a signed statement
x thmhc isliccnseJ pursuanun thepmvtsmns of the Conuaewr's Liccnm Lsw(CM1aprorg gazi3 Valuation
an t—O (commencing with Senion]000)n(DivixionJ of the Business and Pro(essinns Cnde)ur
i $ son M is exempt therefrom and the emu for the aIlc,.d caempt...Any vialaG.n of 3 S O 0 0
Settle.7031.5 by any applicant for a permit subjects toe applicant m a civil penalty Of APN Number Occupancy Type
not more than we hundred dollars(S500). P Y YP
❑1,wownerofshepmp y,ormyemployeewithwagesmtheirmIccompensation,
will do she work,and the structure is not intended oreffered for sale(Sm.]044,Bulinus
and Professions Cade:The Contrznoff License Law does not apply m an owner or Required Inspections
(,,.Perry who builds munprows thereon,and who does such.,it himself.,through his
ownemployme.provided that such improvemeum are not intended at offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving Nat he did on Wild lir improve for purpose of
ale.).
❑has own.of the mo,eny,on uclusivcly contracting with licensed conwaon Or
=$(Met the pmjecr(Sea 7(344,Business and professions Code:)The Contnaor's U. '
c
ens,Law dues not apply to an owner of property who builds or improves Ibemon,and
who emumia for such projects with a emuracmr(s)licenaed pursuam Jo Ge Canuanofs
Lim Law. _
I�.Far^ Bah P C for Nis reason
Dam
L L
WO KEh4CbTAPE ATION /EQLARATION
1 hereby affirm undo realty of 'ury o o'(the following declinations:
❑1 bave and will mainmin a Cer fieam of C.mmn,m salt-insum for Worker's Compen-
sation,as,provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of me labor Code,for the pcolu mor.of the work liar which this permit is issued.
My Worker's Compensation hounna carrier and Policy number an:
Cartier: Policy NO: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the permit is for one hundred dollar(SIIXp
or ess.)
1 certify don in the perfmmanceof a wore for which t o"Permis u issued.I shall not
em,.,,ury person
of Esempti n. ou should
bottom Subject to the woher's nm,ion provisions of the Lahor Code,you most
.J O forthwith comply with Such provinom or this ptrmitshall be deemed nvrked.
z to CONSTRUCTION LENDING AGENCY r�
I hereby affirm that then is a communion lending to the performance,of
Y Co. .) 'r
!x the work for which this permit is issued(Sec.3097, .C.)
(43 C) Lcndcf
Ca )
z Lender's Address
U Q 1 ecnthat 1 have read this application and slam thin the above information is l
W (•" correct 1 agree
m comply with all city and county ordinances Of and sum taws rotating ue
QU above mentioned
and herona,mbimby ordirmine nxnutivu of this City so enter upon the V )
r W anovo-me e)agree
to save for inspceuankeephpurposes, ) J(
gy (We)agree m save,indcmmify and keep harmless the City of Cupertino against /
iUN in consequence
granting ofpenspe which may in any way acrneagamstsaid City
U z APPLICu!,FT of UNDERSTANDS:
S:IyN crmiL�
APPLICANT Y WITH ALL ONPOINT Issued by: Date
SOURCE REGULATED
e11 0 - Re-roofs
Sunman of AppI n m Omracmr Da
HAZARDOUS M ERIALS DI LO RE Type of Roof
Will the applicant or future building occupants re or handle havardous material
or defined by the Cupenino Munici,1 Codc,Cha,mo 9.12 and the Hcalth and Safety
ode,Section 25532(x)? u All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will mea brantpr mwm Wngin .ser am lila e t oraevmea which If a roof is installed without first obtaining an inspection,1 agree remove
pp s v gripmen -
cmit ha ardous air camaminanu u tned by the Bay Arca Air Quality Management all new materials for inspection.
District'
❑Yes u
1 have mad the hmardnus..ol,h is nquinmcnp under C1a,mr695 of the Califor-
.is Health A SalmyCode.Sections 25505,25533 and 25534.1 urohnnand Natiftlm building /D�
does not currently have a mount,that it is my responsibilitynu notify t n occupant of the j
Ccfdficare Of Occupoor. ,Signature Applicant Date .
Owner lir ar hod]Fd ugen � Dat O All of coverings to be.E ass"B"or better