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CITY OF CUPERTINO,�-f^„w�le..,.�.„
BUILDING DIVISION PERMIT
;.lCQN. TRACTURINFORMATIgN
BUILDING ADDRESS:
PERMIT N0.0 6 0 8 0 020
OWNER'S NAME:
PERMIT ISSUE DATE
. FARIDEH MISAMI/ALIMOHAJE
1111111i
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDGO ELECTO PLUMB MECHO
LICENSED CONTRACTOR'S DECLARATION
lob Description
P
1 hereby affirm that 1 am licensed under previsions of Chapter 9 (mmmcneing
with Section 700X0) of Division 3 O she Business and Prafwium Code, and my limns ts
infail farm And eff«L
REVISION TO ORIGINAL PERMIT #06010074
L1CC0'en"'e.g
Dau: Uor
CHANGING FROM STEEL FRAMING TO WOOD FRAME IN
ARCHITECTS DECLARATION
FAMILY ROOM
I undunund my plans shall w used As public Menrds
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby alum that I am exempt from the Contractor's License Law for the
following reason, (Section 713 t.5, Business and Professions Code: Any city or county
which requires a permit to channel, alba impmw, demolish, nr minor any structure
prior at its issuance, also requires Ne applicant rot such permit in rile a signed bmmtneal
he Cammlues Uccae Law (Chapter 9
Sq. Ft. Floor Area
Valuation
Out he I. licensed ponoses to the provisions of
(commencing with Section 70DO) of Division 3 of Ne Busirws.nd Professions Cadel or
_
$518794
that he is exempt Nertfrom and the buts fa the alleged eumption. My violation of
APN Number Occupancy Type
Section 7031.5 by Any applicant for a permit subjects Ne applicant to a civil penalty of
M, mere Nan five hundred dollen ($500}
❑ I,uawnerof Nepmpmy,amyrmploym.ith.rsudt i mte=prn Uon,
will do Ute work and the Amounts u not handed ar Offered Wattle (Sm. 7044, BuUrcv
Required Inspections
q P
and Profession, Code: T1s Councilors U=ntie Law dm ret apply 0 an net of
prepeny who builds or im prove , Utemon, and who does such mor c hinsw r or though his
own employees, provided Nmauch imprevemenu are notinicaud aro@red forsak. If.
however. the building or improvement is into within ane you of eampledan, the Owner.
builder will have Ne burden of Moving Nat M did not wIW or Improve for purpose of
!
build.
\
❑ I, a owner of the property. .m exclmively conaaning with licensed mntrmtpn to
O saw
construct 7044.7044.prefect (See. , Baines and Prefmiam Code:) The Contractor's Li -
LaUs
moaeLbw dm not apply m us own¢ of property who wills or improves and,
ca\
.±
Conti
owith a anor(a) licensed pt m Ne CanwcnYs
who mcu far such projeln mnu
can
License saw.
❑tun ucmpt .BAP i n
Das 10
MPENSATION DECLARATION
1 hereby a im uder penury of perjuryenc of tk following dmwadom
❑Thawtrod will of ConummnR-Murt
37M the
provided (at by Sedan 3]00 of the labor Code, far Ne perfonn.nsO of the
for by Section
r
wad for which this permit is issued.
❑ I have and will mainwn Woder's Compensation Insurance, As required by Scdon
3700 of the Label Call, fa she performance of the work for which this permit is issued.
My Warkee, COmpan mire, Insussme cartier and Policy number see:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu satire xd trot N completed BUe permit Ib farm hundteddoBan ($I00)
or leu)
1 mNfy Nm in the Petro ofys,warit for which this permit u issueq, I NAI not
employ any Person in any an m mbecomesu yet doworkeKC pensscan
laws of Califomu. Do
Applicant
NOTICE TO APPLICANT: If. after making Nu CcAOcam of Exemption. you should
become subject in the Workces Compensation provisions of has tabor Code, you must
faMwith comply with such provisions at this permit Nall As deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that that. uamnbtmction mndmg.ge cy sur the parrarmanxof
Ne .,it rot which Ws permit Is issued (Sec. 3097. Civ. Cd
Lendoe: Name
'
LcndctAdduces
1 I cedfy Out 1 have and this appllcNon and sum Nu the above information u
correct. I agree in comply with all city and county aNinances and sum laws muting m
building construction, and hereby audbome representatives or Nis city to cover upon ds
above-mentioned pmpeny ret inspedon purpa s.
(We) agme to save, indemnifymleu and keep hatthe City or Cupertino agaiat
j liabilities, judgments. costs and expenses which may In any my accrue against aid City
in consequence of the {renting of this permit.
' APPLIC UNDE T DS ANO W L COMPLY WITH ALL NON-Pg3r�r
Issued by: Date
sou
6'
26'
Re-roofs
9Z
Signature of ApplicambComrectat Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Wit Ne applicant or futon building oaupantstam a handle hamdoa material
u defined by Us Copartner Municipal Cade. Chapter 9.13. and the Health and Safety
Semon 255324)7
❑rel
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
If
Will the Applicant or mart wading Occupant a¢ pmmt a d vim whien
emit huardnus air canuminams As defined by the Bay Arta Air Quality Management
all new materials for inspection.
District?
❑Yes
I haw mad Neh nalums memdaumq.irtmenu under Chapter 6.95orthe Calira-
niaHeaiNASofet de Sectio.15505,15533and255}s.lunen dth iMewiWing
dm not to am a when that It b my responsibility m notify 1M acupanwf
require w ch set dor ssaaumm's rdfcam roc
Signature of Applicant Date
All roof coverings to be Class "B" or better
ownn ora ad ascot mm