05030164 CITY OF CUPERI'INO ``..r
BUILDING DIVISION PERMITcONTRACT,ORIlVFORMATIOON
BUILDING ADDRESS: HAYEDE NIUFAR PE1MITN005030I64
18791 ARATA WAV
OWNER'S NAME: PERMIT ISSUE DATE
HAYEDE
NE: SANITARY O. CONTROLNO.
ARCHITECrrEN'GINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACT'OR'S DECLARATION
w❑ 1 Worthy affirm TNI I am[immed under pmvisiom of Chapter 9(mmmcncing ]oto Description
Z. with Sccdan 7")arDivision 3 ofdre Business and Professions Code,and my license is
^may I.Liensea amerce" REMODEL--MINOR STRUCTURAL ,SHEET ROCK
License f Clan Lk.a STRUCTURAL/
SHEET
g p Dale C.musaw,
i I,j' ARCHITECTS DECLARATION
�i m-I I underwnd my plans shall he used as public records
Dcd
0 Licensed Pro(cssianal
3 OWNER-BUILDER DECLARATION
<y 1 hereby affirm that I am exempt from the Comment's License Law for the
00 following Lesson.(Section 7(01.5.Business and Profevions Cock:Any city or county
m which mquime a Permit m construct,aIle,,imgmw,demolish,nr.,.it any structure
priw m its issuaece,also requires the apDlicam far such Fenced to file a signed lummcnl
that he is licensed puomettoWerovisiovofNeCommor
clor'sU.nselaw(Chapmr9 Sq.Ft. Floor Area - Valuat
ret- (commencing with Section 7000)of Division 3oflhc Businevand Professions Cock)or
y
But,he is exempt Therefrom and the basis for the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of 3710Tt Ib*(;r00 Occupancy Type
net mom than me hundred da1lus($50(1). P Y YP
❑1,as owner of the progeny,or my employees with wages re their I.compensation,
will do the work,and the structure Is not intended or offend for We(Sec.7004,Business
and Professions Code:The Contractor's Lieme Law does not apply W an owner of Required Inspections
progeny who builds or improves thereon,and who doessuch work himwlfor through his
own employees.provided that such imprasmena are not intended or offered for We.if.
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
Sale.).
1,as owner of the Nopeny,am.aclusively contracting wish licensed contractors to
construct Iha proles(Sec.7144,Business and Profecoms Cade:)The Conu muni Li.
cense Law docs not apply W an owner of property who Wilds or improve themon,and.
who contracts for such pmjCcu with a conwclo(s lie pursuant to lic Contragar's
se Law.
emexe planer Ce. B&PC for this reason
wren
WORK R'$COM EN r N'D X O
affirm I hereby aon penalty fperj one of the allowing declarations:
❑1 have and will mainain•Ccstifmm of C mem to mlf-imam rw Worker's Compere
sation,as provided for by Section 37M of NC Labor Code,for the performance of the
work for which this Formol is issued.
❑1 have and will maintain Worker's Campemmi(m Insuranc.,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued
My Worker's Compensation Insurance canner and Policy number are:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectior need not kcompkteJ if the permit is for..hundred dollars($100)
or kss.)
I eenify that in the performance of the work for which Nis pe 'I gqissued.1 shall nut
employ any person in anym sin I kcor�e gbcuolk "Acis' omFcns n
Laws of California.Qp Le
Applicant
NOTICE TO APPLICANT If. Lor akin is Ce rfc t- f Eacmprio�ou should
ke...subject m the Worten' Compcnsat on provisio a We laMu Code.you must
.Jz foMwith comply with such provisions or this permilshal Wdcemcd mvnkcd.
ZO CONSTRUCTION LENDING AGENCY
F
I herebyfirm War there is a construction lending agency a B sg Y for Be Performance of
CL the work for which Nis permit is isned(Sec.3097,Civ.C.)
B7 Q lender's Name
Z)z Lender's Address
U O 1 unify that I have read this application And state that the shoes information is
ry F coact.1 agree to comply with all city and county on irreces and sum laws relating to
pU Wilding construction.and hereby authorise npreaenutives of this city to enter upnn the
r W akw-rumboned property for inspection purposes.
(We)agree to Save,indemnify and keep harmless the City of Cupertino against
H N
liabilities.judgments.cents and CxKnms which may in any way stmt against said City
Uz in consequence of the gmmi ng of this permit
^ APPLICANT UNDERST DS AND L COM LY ITH ALL NON-POINT Issued by: Date
S RE 0
r _Z D Re-roofs
Signvum of Ap inmlConuaemr Dale
HAZARDO S MA IAIS DI S E Type of Roof
Will the,applicant or for Wil ' gtsttupml andle hazardous material
as defined by the Cupertino Muni tri Code,ChaFfe .11,and the Health and Safety
Code.Section 23532(4)?
❑Yu All roofs shall be inspected prior to any roofing material being installed.
Will thc epplitanwr future Wilding occupant um equipment ordevicea which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air conaminanu m cd by the Bay Area Air Quality Management all new materials for inspection.
uJe re
DinricR
❑Yes
1 have Load the bavarAwurratedala no,iremcnu under Ch.,er6.95 of Ik C.5(oo
nia HC.alth&SOCCLYCok, us and 25534.1 understand Wutiftk Wilding
Jots not currently neve a e nthar iI is besponsibilisy m nodi occupant of Clic
mquiLomenuw chmm
ust el 'o, usmance.fa Ccnifea Occupancy.
�g 22 Signature of Applicant Dale
0 Crwaathorreda est Date All roof coverings to be Class"B"or better