08010068 CITY OF CUPERTINO ;: €.
BUILDING DIVISIONPERNIIT ^�
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ILDN���D1 ESS: PERMrr NO.
� ARATA WAY TBD — TO BE DETERMINED 08010068
_ NER'S NAME: PERMrf ISUEDATE
JACOB SAIDIAN 01/18/2008
PHONE: SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
300 LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby a0ion Nn 1 am Ihxnaed under previsions of Chapter 9(commencing
.Z1 with SectionTOM)ofDivision3oftheBuiencesandPrafeaeiunsCode,andmylicenseis REVISION,ERRONEOUS LINE DELTD ON RF PLAN; ORIG
^ m full fame and.from.
; z Uanac Claa. Lia.• 07070214 NO NEW PERMIT
p Dam Contractor
7W ARCHMCrS DECLARATION
eI undcrannd my plans shall be used a public records
h sed Licensed Professional
gon OWNER-BUILDER DECLARATION
2 i 1 hereby affirm that I me exempt Wm the Communes License Law for the
afollowing moan.(Section 7031.5.Buiuu and Professions Coda:Any city m county
jai which m fumes a Permit to common,alma improve,demolish.or¢pair any structure
prior m its insulate,ass requires the applicant for such permit to file a signed stmemenl
that an is Rmmed pomm,to the previsions of the Connector's Uuman Law(Chapter 9 Sq.Ft. Floor Area0 Valuation
9 (commoncingwith Sadon70W)of Division)oft.Bushmaand Profeuiaan Cade)or
dot M s eumpl therefrom sed ton bub far the aileged eumpdon.My violation of
Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of A Number Occupancy e
am ream dun five hundred dollars(M), 37512032 , 8 P y'i'p
❑L u owner of the pmpmty,m my empluycu with wags u their mm cmnpewdon,
will do lbework,md theawcture is not intended craffemd mrule(Scc.y .Buimu Required Inspections
and Professions Code:The CamCulminates License Law dean not apply m e ns an owner of q P
property who bulldaarimproses Nereon,and whodeessuch walk himselfer through his
awn employees,provided than such improvements arc not imended oranefM forsale IL
however.the building or improvement is sold within atm yea ofcompledon,the mover,
builder
ov r-
builder will have the burden of proving that Ire did not Wild Or improve for purpose of
sale.).
1,as comer of the roporty.em eulusiwly co ormaing with licensed conwcmn in
annual the pmjcd(Sec.7064,Business and Prefmsions Code:)lha Conmacmis Li-
come law does cot apply on at owner of property who builds or impm res Neeson,red,
who channels,for such projects with a conuuml(s)Ikemed pursuant m the Canindor's ,
Linemen Law.
❑l an exempt under See. jrB&PCms qnp
mer Up('>k �n,/a(v ,.tam I OA
WOR 'S COMPENSATION DECLARATION
1 hereby afliml under penalty of perjury am of due following declaretons:
0 I ham and will maintain aCenificam of Consent in self-Lnum fm Worklls Compen-
mion,an provided for by Section 3700 of the labor Cade,fm On performance of to
work for which this permit is issued.
❑I have and will maintain Warner's Compensation InSannct,as required by Section
3700 of the Labe Code.for On performance mf Oc work,for which this Poland is lamed.
My Workels Compensation Insurance curio sed Policy number art:
Caroler. Polity Na.:
CERTIFICATE OF EXEMPr1ON FROM WORKERS'
COMPENSATION INSURANCE
(Ihia section seed not be completed If the permit Is for one hundred action($100)
or leu)
1 certify that in the performance of Na work for which this Permit In leaved I shall non
emplayamy pan..in try munormum ubie the Wmkaa Cempannton
Laws of California,Date GG
Applicant
NOTICE TO APPLICANT.If,after making this Certiftcam of Exemption,you should
became subject in the Wofaces Compensation previsions of me labor Code,you muse
Q O forthwith comply with ouch provision,m this permit doll M deemed revoked.
wZwCONSrRUCr10N LENDING AGENCY
[r I hereby affirm than than,is a construction lending agency for the performanro of
G' > the work fm which this permit is issued(Sec.3097,Civ,C.)
W� Q Landoll Name
a Z Iendels Addreat
t.>Q 1 certify that I have mad this applicaden end sus tea the above information Is
fL!' cannon.I ill=in comply with all city and county ordinances and smut laws mlai ng it,
_Q SV^ building convection,and htmby aumoriu repnsenu0vu of this city tu color upon On
W ahove-mentamul property for inspection pulp=&
py (We)agree to urn.indemnify and keep hawlea the City of Cupertino against
Ilabilltics,judgmens,cost sed expenses which may to any way...against mid City
[� in consequence of the gnrntng Of this permLL
APPLICANT UNDPRSTANDS AND WILL COMPLY WITH A{{sssLLL NON POINT Issued by:9 Date �agGd"
SOURCE EGU O/NS,S, ` // J 1 Ga
Re-roofs (7
Signau ppli rd ntr 0US MATERIALS DISCLOSURE / Dow
HAZARDOUS Type of Roof
Will the applicant or fuume building occuPutaoe or haedle boredom maloriat
as defined by the Cupmme Municipal Cade.Chapter 9.11.arm the Health and Safety
.Scmien zss3z(a)7
❑Ym Na All roofs shall be inspected prior to any roofing material being installed.
I PanWill On applicant or future building eceupont use equipment or devios,which If a roof is installed without first obtaining an inspection,.I agree to remove
..It hea mlair con ons at defined by On Bay A.Air Quality Management all new materials for inspection.
Diatdct7 am
Oyu
�Nu
I have real the haaN<as materialsomuiememu under Chapter6.95 ofthe
Safety Coda,Section,25505.25533 and 25534.1 understand thatifthc Wilding
does Ion currently haw a tenon,Our It is my responsibility m nadir the occupant of On
mquimmc lawn' mutbe men priormiuuatce ora Cenifaam ofN Signature of Applicant Date
,/ " A All roof coverings to be Class"B"or better
Ownc stump-ved.9ml Dam'