05110011 CITY OF CUPERTINO * "�P�ry.p' �I�"( "�/ �f °^'�" (y��{ '00
BUILDING DIVISION p�'Ry r� anl+�L'li'111a^].11W+�. `' � ^"' �
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BUILDING ADDRESS: PERMIT NO.0 5110 011
10534 GASCOIGNE DR
OWNER'S NAME: PERMIT ISSUE DATE
KHOSROW KHAGHANI
E: SANITARY NO. CONTROL NO.
ARCHMCIf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p t�
lop LICENSED CONTRACTOR'S DECLARATION lob Description
V I Wmby affirm that 1 am licensed under provisions of Chapter 9(commouln{
with Secdon 70M)of Division Sof the Business and Profnasiawde
Ca .AM my license is
+� tfull forceand.ff SFDWL-ONE STORY 4170 ' LIVING-GARAGE 500 '
1tq4 License Clns La.gfi�\ .�.��
;r� Dated/1LJ_sG_conuseta�T7�— BASEMENT AS 2ND UNIT-SANITARY SUNNYVALE ' S
p
1 understand
nw � XRCn used
DECLARATION
I t� dernd my piashall
be W need u publte vecorm
G Licensed Professional
m Oat I am exempt
DECLARATION
a I Wreby.film that I e.5,Burin from the Casionsss License law for the
5 D o following namn.Permian 1071.5.Business and w.dem ll Code:Any city or County
5$lis which requires a pewit 70 tins acct,atter impmn,dem it t ore ,l any 1111m ro
zi that Wiubalance,
ensedPatuanttoiw tMAppRcant for flocl Cormteittanlcasipncdsutemcm Val"12Q112
�< Ghatnflis umi gwit pursuant 7000)Of Diviow of dte ConuacWr'snd PrucLaw(Clnpmr9 Sq.Ft. Floor Area Wean
(cameis exempt
pt Secdon1000)MDivbion5 nfth)egedBusiness Orlion.My
nn.Code)vilation or
Nn io r am.5 b taemfrom and We aper it the subjects
the exemption.Any it penalty of
Section than five
Aly applicant for A permit mbjeeu Ne applicant to a civil penalty of N Number Occupancy Type
Car mom than rave hundred dollar($500). 3 /�23010 . 00
❑1,u aamr orthe proprny,u my rmploye"with wgca u Weirsalt cm Wmdae.
.111 do th)work.end do suumn,rmtin¢Medm-fil"M hassle(Sec.IDN,Business Required Inspections
Nd Pmreadou Cod&The ConnactaYCA sa
e License Law COCA Apply m an awKl of q P
pmpwy who build,N improv thmeneatw wbodausuch work hbauelfm Waugh his
awn employces.provided Wmauch improvements are wtlnuaded uoRerm f"elle B,
bawler,We building or Improvement is mid within oro yeas of cmnptetim,dre owmr
builder will Nve W holden of proving Cut he did CoA build"imp xwO for parpne of
sate.).
❑1,as aarmr or the property am exclusively contracting with IIcemW Contraclora W
Construct We project(Sec.7W.Business no Profesdau Cade)The Cmuacme's U-
Came law does not apply W An own"of properly who Wilds or Impow theme.and,
who contracts for such Projects with a conwnor(s)licensed pursuant W the Conuamo's
1.1c"um law.
❑I em exempt unde,Sea .B&PC for this mason
Own" Thu
WORKERS COMPENSATION DECLARATION
R1 hereby affirm under penalty of perjury am of the following declarations.
an am will maintain•Ccnifscau or Cament in self.Won for Worker'sCompea-
Ndon,as Provided for by Section 3700 of the Labor Code.far We perfarmmer of We
wart for which this permit is Wend.
lb I ban and will maintain Warless Compensation Insurance,as required by Section .
7100ofthelabor Code f"theporfar Carreof work fnwhich this permit rIssued.
My Work)rs Campewtim Iwuran¢osier andd Policy number an:
camar. CERTIFlCATESC I I: policy,1policy,No.: 1 1 9 111 % C 4
OF EKEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section wed rot W completed Ifthe permit Is farone hundred dollars($100)
or Isere.)
1 certify Not in the performance of the work for which this Permit be blued.T shall not
employ any pumn In any manmran u W become subject to W Warkers'Compemadon
Laws of CAlifomiL Dam
Applicant
NOTICE TO APPLICANT.If,after making this Cerlincate of EmmPtian,you Mould
became subject m W Workers Cmnpauadon prevision of W labor Cade,you mon
vJ O raMwiW Comply with such provisiou"this Permit that be demand masked.
Z CONSTRUCTION LENDING AGENCY
(.. I bomby,Art Nat Were is a mmmoctin t lending agemy for the pefforounce of
t1, W work for which itis Permit is issued(Sec.7091.Civ.C.)
W Q Landers Name '
7 lenders Aliment
U O I CeNfy that I hart mad this application and,tsm thin the above information is
W F concct,l agree 70 comply with all city and county aldlnutees and Nm law m1atiR W
OU building construction,and hereby authorise representative of this city to enmr upon ft
r W ahuve-mcnduned properly for inspection purposes.
and
the City Of
rtino
aims
Nliabilities Judgments,cree to osts d expee. nses which may in any my urn'e�ainu,dd City
U Z to CorreonOr the 11.
APPLICANT UNDERSTANDS ANDWILLWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREG ON .
l t 6 Re-roofs
Si, cel Appli nRer ��qv$�"U E N}hp`s Type of Roof
NA7.ARDOUg DOMATERI
Willby t Applicant or Comm Wal Camavpmt r num 9.12.h.ndle Health us And Sa riai
u denrcd by the Cu Mumeipal Cade.Chapter 9.11.and the Health and S+fmy
Code,Section 2557x(.)7 All roofs shall be inspected prior to any roofing material being installed.
l]Yca NO
Will W applicant or future Wilding oavpast use equipment per devices which If a roof is installed without first obtaining an inspection,I agree to remove
it huardnw air conu mane denned by the Bey Ams Air Quality Management all new materials for inspection.
Di:Rdct[
❑Yu No
I hoc read the Nowdow materials requirements underCWpter 6.95 of the Califon.
.is Health&S,fmy Calc,Sce dow 25505,25537 and 25531.1 undcnund that(W building
does am eminently hen•tenant that It to my responsibility 70 marry W ncCopant of We
mqulnments usWmetpriarWiexam)nncmtinc.MorOccupancy. Signature of Applicant Date
IN S a 6 A All roof coverings to be Class"B"or better
Owner or Authorized agent Dote