05090233CITY OFCUPERTINO`+`"%`��«
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
C FARSAI
PERMITND.05090233
10106 CARMEN RD
r 'NER'S NAME:
PERMIT ISSUE DATE
4 28 2006
ONE:
SANITARY NO. CONTROL NO,
ARCHITECUENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
- job Description
I hereby affirm that 1 Am HUA Wd under pmvisiom of Chaper 9 (commencing
3of Nc Business And Profrsmom Codc,rM mylice�is
dbb Section and Affect.
in full ctio and affect
ADD 481' -FAMILY RM/FOYER ENTRANCE -REMODEL 2507'
Class Line
Dadc
Dole ContractorDELL
ARCHITECTS DECLARATION
N Used
I understand my Plrm slW I he uud a public records
LKCR¢d PmfGbIONI
OWNER -BUILDER DECLARATION
1 herehy aRrm that 1 am exempt from the Contracors License Law for Oe
following Lesson. (Section 70315, Business and Professions Code: Any city or county
3 5 4 9 9 0
witch acquires A Permit m enrlLNct, Alan. Minnow. dem.iU, ar Rpal, Any xWctUR
prior m its issuance. also requires IM appliart rat such Permit m Ohs signed stnenmm
Sq. Ft. Floor Area
Valuation
Nat he u llcemed pursuant to the provisions of the Contractors Liuenm Law (Chapmr9
(commencing with Section 7000) 9Division 3 of the Business and Profession Cade) or
Nat he Is Cxempt therefrom and the basis for the alleged temp tan. Any violation of
y
Occupancy Type
Section 7031.5 by Anil' applicant far a permit subjects the applicant m A CIvi1 Penalty of
mot mart Nan few huedmd deaths ($500).
❑ Lasawueroftim property. mmyemploym with wgeaamhwic mpmadon.
Re aired Ins ections
q P
willdodawalk. and NeeWcm. lrmamundedaraRGRd faraala ($CC.7BaA,BYAiI1Cii
end Profinalmu Cade: The contractors Lt.. Law doe ant apply man owner of
propertywho builds arimpnaw thercon, and who dmauchwark himselfor amugh his
own emplaym, proAded thalreeh impmw:manu ree antinutded maRered for $age.If.
howews, the building or impmwmant scold within am )ear ofwmplettan. be owvrs-
builder will law the buNen of Proving that he did and build m improw for Puryme of
stake).,
{]'1, as ewer of the property rm axelasiwlY wnmacting with licensed cimmcmn m
caetmct the pmjem (Sec. 7W. Buglers AM Peabedom CMc) M Coouacmrs Li -
cons, Law deal of apply is an ownr of Property who builds At improve ft.. cod.
who <onuacu fro such Peojeets vIN aconuacmrtq Ikemed pwwmt m the Contractors
Lkenac Law.
❑lam mumPt0
of the fallowing declAnaiam:
❑ 1 ham and will maintain a Certifiam of Cement m self -imam far Workers Compen.
anion, a provided for by Section 3700 or the LAW, Coda. fro the peefermance of the
work for which this permit u issued
Q I low and will maintain Workers Compensation Insurance, a Rquted by SemtaA
,
37M of the labor Code, for the perfoammecof the dak for which this Permit Is imed
My Workers Compemamin Inmtana wrier and Policy number Am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
v
(Tbbeection need mlhecampked Ifde permit is foeana hum@ H.(5100)
or Use.)
1 certify that In the
you Ymuk
NOTICE f�linau of FiAW
13 Ca,
became tromp m art Works Coln provisions of the hear Cade, you mmu
re
forthwith comply with such prevision or this permit shall M deemed Rvaked.
or t
LENDING AGENCY
CONSmisa
I hembycnrm tiFo them us eg0Nnation leMint atendry for the pen(amarce of
.
Issued 30
the does for which this Penult u issued (Sec. Nth'). Civ. C)
Lenders Name
Lenders Addam
1 certify that 1 haw and this application and sum the the abaw Information Is
cormet. I a{aee in comply with all city aM county org n fees and some laws Mining m
building construction, and herby aLNorite Rpresnnudws of this city to order upon the
ahaw-mentioned property, for inspection purposes.
(We) agree to saw. indemnify and keep harmless the City or Cupertino Against
Imbilitie,Judgments,cmta and expends which may in my way ream gtlmtddaly
in conaquersc of etwang of.th'
APPLICA ERSJ 6 D WILL OMPLY WITH ALL NO
Issued by: Date
Si 'neat MATERIALS DISCLOSURE Date
Will art applicant or futue building ompantrtaR or handle hAAAWUA mamrW
As donned by the Cu etino Mai i - I Cade. Chapter 9.17, AM the Hdth and Safety
. Section 2.553z(U7
All roofs shall be inspected prior to any roofing material being installed.
❑ Ye e
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant in future building occupam um equipment or device which
MIL haysmnm AircanummAMJ As dc0rcd by the Bay Arta Air Quality Management
all new materials for inspection.
Diorite
❑`ha a
InawasuithalbotairdnmmamriabRqquimmenuunderCmPmrQ95arNeCalifor-
ntaHcalthk efy- &, Seetiam331a5,33535 ess53a.1mrecnlnM thmiflhc balding
der on, ntiy ow �parh is my RA adhility m unify Ice occupant of the
meal cnuw 'u aj"fef rior.m:, a ofacmnireamaroccupanLT.
Signature of Applicant Date
All roof coverings to be Class "B" or better
n ,aRari case Dam'