05010042 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,CC NTRA�CIOR NFU. ATION"'
'BUILE" IT
GINGADDRESS: ESMAEIL NEMATI PMND'05010042
)Ov ER'S NAME: PERMIT ISSUE DATE
ESMAEIL N 06
E: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
Z BLGO ELECT O PLO MECH
O
Sop LICENSED CONTRACTOR'S DECLARATION JobDescri Description
+� 1 hereby affirm Net I am licensed under prevlsians of Chapter 9(commencing P
with Section 700gB or Division Sof Ne BuM eamand Prefnuhrm Cmk,and my kens,is
infull oClass eat SFDWL-2, 244 LIVING/GARAGE 441 '
Lieeaa else Como 1/3/6 SIJNNYVALE RESP FOR SEWER
3
Data Can DEC
ARCHITECTSIWusDECLARATION
I understand my phos tIW I bo used u public record '
J
Licensed Professional
OWNER-BUILDER DECLARATION -
I heresy affirm that I am exempt form the Convenor's License Law for the
O O following recon.(Section 7031.1,Business and Pmfmdam Cade:My city or county
$ which mamma a Permit in,eamwe4 alcor,imprmse,demolish.or repair any mnetum '
prior to I%issuance.also requires the applicant for such permit to file a signed natement
< Ulel he is licensed pursuant to the provisions of the Contractur',License U.(Chapter 9 Sq.Ft.Floor Area Valuation
a (commencing with Section 7000)of Division 3 of Ne Businewand PorfieWom Code)or $336000
Nat bo Is exempt Merchant and Me basis for Me alleged exemption.My vloladon of
Section 7031.5 by any applicant fm a permit subjects the applicant to a civil penalty or enc ApN Number Occupancy pry'
trot mon Nm In hundred dollars(5500). P Y '7 Pe
❑I,u owner of Me property,or my employ=with wages u Pleb sale eompemWon,
will do the work,and the svumurt Isnot Intended or offend formic(Sec.70414,Business
and Property
whlon,Code:The Contractor's License law d=not apply lf an owner of RegUlrOd� $� ��
amcoywho Wlldaded that
nsch lmp,andwhowmmu d=sectende moffiror through his
f, Tom/—�{A
awnemploy=,Provided pr suchimPmsemwtart not year
ofdmartued fm oak If,
however.Ne building or improvement is sold within oro year or completion,the owner
builder w'1 have Ne burden or proving Nat he did not build or Improve for purpose of
ale.,. Vie.
.u owner of the Property,am eaclutiwly contracting with licensed contractors m
comicLconstruct the es not appl(Secy
toa n Business and Py.who ns Cade:)Themm Maroon.W M
cense law dm{notch Pr to an owner of pmpeny.who Wilda n Improvhe Neuron,and BUILDING whonse LacLL for Projects with 0 contractor(s)Ilamed pennant m the Convactorl
License Law.
❑lam can uSec. ,B g:P C fm Nis moan
I
r Dated-40b
WO S
'COMPENSATION DECLARATION
I hereby ma under penalty of perjury ane of the following declarations: -
1 haw and will maintain a Cenfflao ofCansenuo self-insure fm Woftes Camino.
cation,as provided for by Section 3700 of Men Labor Code,for that performance of Ne
wars for which this permit in iaslmd.
❑1 have and will maintain Wurkees Compensation Inaranco,as required by Section
3700 of the labor Cade far the performance ar Ne work rarmich this permb h issued.
My Worker's Compensation Insurance canner and Policy number ale:
Cartier. Policy No.: _
CER7IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Td see0on need amt bo cmnple"limes Permit is(=aro hundn9dollan($100)
art..)
1 certify Nm In Ne Pmfortnana of Me work for which Nis permit Is W d.I shall not
employ anypcnon in any manrJgrw=.x m Ur.War ne'Compensal.
Law,or Caliramla.Dam—
Applicant
NOTICE TO APPLICANT:If.efmr malting this Cer ificate of Exemption,you Mould
become subjm W fie Worker's Compensation proNsims of the Lebo.Code.you most
.,O forthwith comply with such provision or this Permit shall bo domed revolted.
y CONSTRUCTION LENDING AGENCY
Ew I Wreby affirm that Nen Is a eonnmctinn lending agency for Me perfurmma of
ai
the work for which this permit is iamd(Sec.3097,Civ.C.)
W Q Lender's Name
z Lender's Addans
U O 1 awry that I low=d this application AM main Nal Na abow information Is
IL F" con=.I agree to comply with all city and county on inantts and some laws relating to
pU building construction.and hereby autharin repreaentadws of this city an enter upon Ne
W ahove-mentioned prepcny for inspection purposes.
(We)agree to saw,indemnify and keep lumnica fie City or Cupertino against
r y Iiabllitins,judgmems,costs and expenses which may In any way amus against said Cityin
U
APPLICANT C
f the ANTUNDER cot gOS AIND mI L COMPLY WITH ALL NON-POINT Issued by: Date
souR!SOURCER
EDULA N .
I— y _ Re-roofs / ^—
SignourtorApplican r Data
R US MATERIALS DISCLOSURE Type of Roof
Will Me applicant Or future Wilding occupant mom or Wndie Iloallom maerid
as d0ned by Me Cupenim Municipal Code.Chapter 9.11.and the Health and Safety
I
,Sccvan as3z(.r. All roofs shall be ins acted riot to an roofin material bels❑Yea a P P Y g g installed.
Will the applicant sur ftum building occupant um equipment m devl=which If a roof is installed without first obtaining an inspection,I agree to remove
havardnus air contaminants u de0nnd by Me Bay Area Air Quality Mmagcmenl all new materials for inspection.
ict1Dye,I have aeal Ne hvardous materials requirement,under Chapter 6.95 of die Califonealth&Safelyt2y de,S wdom25505,1353 d15534.lundertondlhmifNeWilding
rot =alllyA mat iPl.Net it hl uspamibility m ntify Me mupml of the
mme A'iich muss hiyet pricer m ce ofd Cwfiamof Occupency.
k ` „ _Q Signature of Applicant Date
Owror mnari a I Dam All roof coverings to be Class"B" or better 4