08030047 CITY OF CUPERTINO
BUILDING DIVISION MMUT i';CUN RACTORkI,.N OItM TION
BUILDING ADDRESS: PERMITNO.
10484 BYRNE AVE REZA RAFII 08030047
WRR'S NAME: PERMIT OUR DATE
EZA RAFII 10484 BYRNE AVE 03/10/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHI ECT)ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 l�
u O p LICENSED COKMACTOR'S DECLARATION
�� 1 limb,AM.Wt 1 Am licensed Ember previsim oor Chapter (commeming Job Description
i with Section700MofDivision 3oftheBusinesssed Pmfcasi«uCode.abmylimeseu DEMO SINGLE FAMILY DWELLING
= in full force and effect.
Limme Clan U.10 .
x Dak Contractor
ee ARCHITECTS DECLARATION
6 O 1 understand my pians WWI W used As public Emma
y G Licensed Professional
OWNER-BUILDER DECLARATION
i 1 bereby Affirm that I am esempl from List Contramors License law for Lit
O O fallowing mome.(Section 7071.5,Business and Professions Colo:Any city or county
CIE which requires A Permit to cnnstmcL after,infirm.demolish,or mpair any momism
S°
Ann m its issuance.also requlms dm Applicant far such Permit LEE Ole asigned statment
< that be islimemul u..,tothe Provisions ofdid,COOUKbf'.U.. U.(Chapter 9 Sq.Ft.Floor AreaSValuation(comm eAcingwith Section7000)ofDivision7oftheBusiness and ProfessionsCod $e)or 6000
that hea,emmpl tumfrern and the hula for ae a1kgW exemption.Any AlAnIfon of
Semon 7051.5 by any Applianlfors permit subjau the applicant D s civil penalty of 35714013��Number Occu ane e
and mem than five hundred dallars S500I. P y TYP
❑Iso ower]ofW property,r my wpbsubc with erml uWeltsole compewness
will dothew«k,and the smcdmknotin¢ndmeraw dons,breakapply 70an Business
of - Required Inspections
and property
wh obu carie:The cmhaabrs License law dam not appy lf rt owner of q P
propertywhobuildsearImproves buns andwho aresamhw«k MmselfedWrsale hk
howWE ever
n,pmgd bropro that himprowmmtsin not ear ofeerrOned da ohmmL
however W Wilding w Mprowmem 4 mid within one year of compktian.the awrcry
Wilder have List linden ll of P oat M did not Wild«bnprow f«purpose of
sok
I.u awmr orW property.Am exclusively conning with licensed mnRaCdM to
construct the pmjen(Sec.7W.Business and Professions Code:)The Conbsemrs Li-
mon law dean not Apply to an ori or of property who Wild proves 0ereon.rod,
wWcomncuforsuclUprE sw' amnuacmrts)Iim pursuant se the Conitanara
License Law.
❑t un exempt order .B k P C for
DAD rh/'/p'tl/1pcaP/I//worry],
W MPENSATION DECLARATIONZ /
1 hereby afrm under Wally of perjury one of the fallowing deelentwo: _
❑1 ham and will maintain a CerstOota of Consent to self-insum for Wrrteh Corrine.
What,as provided for by Section 370th a that Lab«Code.for the pautermahhce or List
work for which this perm,is issued
0 1 haw aM will maintain Walsers Compensation Insurance.As required by Section
7700 of the later Code,for the performance of the work for which Lits permit is Issued '
My Wofkee,Campamulon Imes.artier and Policy number Am:
CAmw. Puliry No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Iles semen need mm W compkmd ifyhe Pemlt D feram hunamd doBus(SIOq
ass) k/
I certify Wk t ae perfomanm e w f«which this Admit ta Isshstg hail cad
empiayanan
ypaninanyman mol ccomesubjectmLiew A a emaa '
Laws of California-Data
Applicant
NOTICE TO APPLiCAN7'. Mr mAkIng this-17tunificatic or Exempt ,you 4lould
become subject to the Workers Comperandon provisions of the Ia1ar Cede,you most
Q O forthwith comply wit inch provisions or this Permit Nail be dimmed rtvoll
'Z CONSTRUCTION LENDINGAGENCY
I hereb afMn that them u a canswction Lending F r . ienal'ser the pertdmance or
the wort for which th4 permit ts iuued(Sec.7041,Civ.C.)
W p Lender,Name
�z Lander,Address '
(„)Q I mortify that 1 haw rod this pplication and cut that the atom information in;
W coma 1 Agrtt t comply Ma all city and county ordimnwe ms and AIns mlatng D
Q rV' Wilding construction.anal hereby waofix rcprexn M of that city m rotes upon Use
W ab m.."domed property f«inspection purposes
py (We)agree to taw,indemnify and lump hum da City of Cupertino against
fq liabilita,judgments,case and tape.whichmay my w'ay Access against mid City
V 7 inconxgmnceofthegnntnaof au ml
r� APPLICANT UNDERSTAND A W L C Y WITH ALL NON- OINf Issued by:9 Date
SOURCE REGULATIONS.
Re-roofs
signature orwpplicml/ConOw
H US MATERIALS DISCLOSURE Type of Roof
WILL the Applkanlar arum Wilding 0
porphat stare or handle hAallous material
deamd by the Cupertino Municip l Chapter 9.13,and the Health and Safety
.section 35572(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yen a
WILL the applicant or future Willing gce'upAnt use equipment or Ucvftma which If a roof is installed without first obtaining an inspection,I agree to remove
emit hramous sir cmtaminsnu ss Ucfi y the aay Arta Air Quality Management all new materials for inspection.
Disc n7
0Yes
Thaw Dadthehundhus.HiLsmquii Encwunder .Chspkr5.95oftins Csiifor.
nallJESarctyCodc,SdU.Z350.�,15571 a dM534.1unJcnt ifac Wilding
Jaen currently cuntly ban A tnmt thgNfk i mApomibility D ratify Lha«ct,h nt of ac
ruquirementa which must W or m of a Certificate of Occupancy' 1. Signature of Applicant Date
Dwnd«mthori>ea.ge All roof coverings to be Class'W'or better