06120014 I
CITY OF CUPERTINOr ,
BUILDING DIVISION PERMIT R ®NIRA . 0R INEQIRMATION,
9
BUILDING ADDRESS: - PERMIT NO.06120014 6120014
OWNER'S NAME: PERMrTISSUEDATE
NAZEEM NORDEEN 12 /11 /2006
Ec SANITARY NO, CONTROL NO,
ARCHITEC(ENGINEER: BUILDING PERMR INFO
BLDG ELECT PLUMB MECH
C= 0 0 0
00 LICENSED CONTRACTORS DECLARATION Job Description
tae I hemby affirm that 1 am licensed under provisions of Chapter 9(commencing
FIs with Section 7")of Division 3 ofthe Busineused Profession, de, rd my he..ut
mfull mroeamdcfrea 441 PHOTOVOTAIC INSTALLATION
o 2;I z License Class Lic.N
;;Q Dam Contractor
ARCHmtCTS DECLA ATION
11 1 understand my plans shall be used as public records
tyu
G y Licensed Professional
OWNER exempt
ER ns he CoAT10N
�n 0 1 reams alum Not 11. eBusu from Nc Conuacm o License law for me
O O following mason.(Section 7W alre Business and ".d ''tans Conk:Any city to ecumty
t_ which require a permit w cnmstrOct alter,impmve,demolish.or mpain any stmetum .. $20000
_I< prior to its issuance.also requires the applicant for such permit be rile a signed statement
that he is licensed pursuant to the provision of the Conuxcmrs License Law(Chapter 9 Sq.FL Floor Area Valuation
4 (commencing with Section]000)nf Division 3 of the B usiness and Professions Code)or
i $ Nu he is exempt therefrom and the nista for the alleged exemption Any violadon of
Section 7031.5 by any applicant for a permit wbjees the applicant to a civil penalty of r Occupancy Type
not mart than Esc hundred dollars(SSW}
❑I,as owner of In,pmpt sty,or my employees with wages as their sole compensation,
will do the work.and thesWcm.is mat mumded M 08[md lotaale(Sec.]04a.DeallmV Required Inspections
and Professions Cade:The Contractors License law door WE apply w e an Owner of q P
property who bui his or ire poli.dans u m.and who does such work h',nset f or Nmugh his
own emPloyces,provided that such improsemencs are notimeMed oroRemd for sale.If.
however.the building or improvement is cold within one year of completion.the Owner-
builder will have the burden of proving that k did rot build or improve for purpose or
sale).
❑1,as owner Of dte property.m exclusively contracting with licensed contractors b
tmetmat on,projcn(Sec.7044.Business and Professions Cade:)Tim Conuuw's U.
cove raw does not apply to an owner of property who builds or imp em thereon,and
who contracts for such projees with a contracmn(n)licensed pursuant in the Conusetors
License La
❑1 am exempt under Sec .B A P C far Nis tomo
sonar Dam
WORKERS COMPENSAMN DECLARATION
1 hereby arDren under penalty of perjury One of the following declinations: _
I hsrz and will maintain a Certificate of Conserv to mlf.insum for Workers Compcn-
scion.m provided for by Section 37M of the labor Cade,for the perrormarcc of the
wort for which this Permit is Irani
❑1 have and will maintain Workers Compenudon Insurance,as required by Sudan
37W of the labor Cade,for on:peromaanre mf Ne work for which Nu permit is issued. '
My We , Cpemom In voce coria and Policy number am:
Cartier. f f• Policy No.:
CERT7F1 ATEOFEXEMPITONFROMWORKERS' -
COMPENSATIONINSURANCE
Crhil section sed not Ic completed if tk permit is for one hundred dollars(51 W)
or Im".)
I certify that in the purf.ru mce of Ne work for which this permit is iswmd,I dull not '
employ any person in any manner ed as to become wbjen to the Worlm s'Compensation
Laws of California.Due
Applicant
NOTICE TO APPLICANT:IL after making this Cenifiuw of Emmptian,you should
become sobim w me Worker's Compensation provisions of Ne labor Code.you must
.J z forthwith comply with such provisions or Nu permit shall W deemed mwked.
Z rjy CONSTRUCTION LENDING AGENCY
(-a Ihemby.M.Nat them is acormrucdmr lendingagcncy for Ne performance.(
a
the work for which this permit is usual(Sc..3093,Civ.C.)
OW. Q Landers Name
z Lender's Address
V Q 1 certify that I have mad this application and sone that Nc above inf ernadon is
e.L f-' torten.1 agree to comply with all city and county ordinances and sus laws relating in
rJU Wilding concoction,and hereby authorise representatives of this city to enter upon Nc
.� 14 ahuvum ptigndpmpcny for inspccumn purposes. /"^�/VC/V/
(We)agree to save,indemnity and kecp harmless the City of Cupertino against
Uh in
thocuss and Of this crwhich may in any way eecmc against said City
V z A consequence of the RSTAN Of Nu permit
^ APPLICANT UNQERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
sOU E�REGNUv{(l{IIII IONS ' V"/
atratax of Applicarn/Commcwr ' ate Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will do applicant or rutwe building Occupant store or harble hammov material
v defined by Ne Cupertino Municipal Cade.Chapter 9.13,and the Health and Safety
_ we.Senium zss3xa)± All roofs shall be inspected nor to an roofing material beim
❑Y.J.r phis P P Y g g installed.
Will mea applicant an future building Occupant use a If a roof is installed without first obtainingan inspection,I agree to remove
nn g v a Air a or devices which P
emit hanNnv air contaminants u,kfir¢d by do Bay Area Air Quality Managcmcnt all new materials for inspection.
Duvicr
❑Yu
1 have mad the tun ardous materials requirements under Chaperb.95 of the Gliror.
m-Health&Safety Oude.Savors 25505.25533 and 25534.1 understood lhatifdc building
dors not currently ha`e a nant that ii u my=Nmihiliiy w nadfy do Occupant of the
regmymentow n/� he metpdarwumecOf.cmrKawafa Signature of Applicant Date
own( .rout mrned gent Daw All roof coverings to be Class "B"or better