06040116 CITY OF CUPERTINO
BUILDING DIVISION PERMITCCINTR,A-C �Qt" M �3 ,, ,,.
BUILDING ADDRESS: KEN KHAGHANI PERMIT N0.06 040116
10534 GASCQTGNE DR
OWNER'S NAME: PERMIT ISSUE DATE
KEN KHAGHANI
NE; SANITARY NO. CONTROL NO.
ARCHITECT713NGINEER: BUILDING PERMIT INFO
BLDG
l� l� PLUMB
t� t�
j0, LICENSED CONTRACTOR'S DECLARATION Job Description
1H with
thereby of ore that I am licensed under previsions of Chapter 9(commencing
Section 70110)of Division 3 of the Business and Professions Code,and my license u
+� ifull force andercecL DEMOLITION OF A SINGLE FAMILY RESIDENCE
?�? License Class Lie.At
3 Dam
ARCHITECTS
DECL DECLARATION
1 I understand my plans shall W used As public records
s G Licensed Professional
y OWNER-BUILDER DECLARATION
aI hereby affirm that 1 ane uusin from tits Cmuns Cod -Any c law for tits
o fellowhich M mason. siren h 703 alness and veer Professions Code:Any city or county
5$ which requima a perms,re requires
Mconstruct,alma Improv demolish.or mlmir many atmmum $5000
ii
prior ms iuwm:e,rsu requites provision of forMe Cohper.itLcense Law(Chapter
<
0Lhan ingwdpmatmltothcpmvisiomofofMeBuecros,AndPrvclaw(C Code)At Sq.Ft. Floor Area Valuation
1
(commencing with section 7000)Of DivkionJofthe Busineumd Profeuiom Code)ur
Nat he is exempt themfrom and the hhem for the alleged eawption,Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil pmarty Of Occupancy Type
at m N
omoan five hummed hollan Mon
❑L ss hewer of ink proprny, am,
Amodss veldt N{ee Ne'v sic Business will apthe work.CWe;The The Cmumemes mndederaw do(Arminapply in an Owner
Required Inspections
and property
who
Code:The Conuanofh License law does net apply lf an Owner is q P
ownenyelm Wilds i i.pmwth imnmdwho da Act inm do b offered Wou{h his
how emt.the Wilding
maraah Imp.wmmts are oat tended"offered Torula Ir.
bowever.ig WilEing or Wpmwmmtbsold ewithindiet year ofmmpinforpuowner-
.M.).rwed have the WNm or proving Nat he did net Wild mWprow for purpose of
tale.).
Ras Owner of the property am exclusively convening with licensed mnuaetan to
mm the project(Sec.7044.Business soli Prefessiam Code:)TW Convaamr's U-
Law dour As,apply m an owner of property who W Ods Or improves thereat.and,
who contracts for such projects with a convactar(s)licensed pursuant m the ConvamYs
Lions law.
❑l ese.ptun fr Sec. ,fid P C for Nu meso.
� 'a' S&t C
's LARATI N�
I hereby alNm under pemhy or perjury oro of Ile fallowing deelaraGom:
[ham and will maintain a CeNOmta ofComent mutf-Isms for Watker'sCompen-
aation,u provided rot by Section 3700 of me labor Code.for the pefa mmm of the
work for which this permit is Wood.
❑I have aim will maintain Worker's Compensation lwreme,As nquircd by Section
3700.f the labor Code,for me performmm of tita work for which this permit is themed.
My Worker's Compensation Insurance nmcr raid Policy number am:
Cam¢ Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(lTlxNnn sed net W complemd ONe permit Is Forane hundred MOan(5100)
or iasis)
I certify that in the performance of the work for which this permit is issued,l start oat
employ anypcmm in mymanmcra arm m c 'ect meworten'Compensation
LAW a of Cali ia.Dam
AppOunt a y Dvy.
NOTICE TO APPLICAN1%IL after n :Ing Nita CwHicam of Exemption,you should
become subject As the Worker's compensation provisions Of the labor Code,you most
.J O faMwith comply with such provisions or this pit shall W deemed mwked.
z 0 CONSTRUCTION LENDING AGENCY
[. 1 w. that ine
y 0111.tIrt Is a consoued r n lending agency for the performance of
C
'54:
me wmdt for which this permit 1 issued(Sm.3097.Cot.C.)
C1.n~.
Undoes Name
a z L.Mlmes Address
V 0 I eenify that I have mad this application and tum than the aWve information is
Uy P correct.I agree to empty with all city and county Ordheanwes she sou len.kting to
pU building constrolion•and hereby authorize mprmcnutives or this city to enter upon dm
{sl above-mentioned property for impcnion purposes.
G (We)agree to taw.indemnify and keep harmless the City of Capenine agsimt
ti y liabilities juig.ents,cru and expenses which may in any ray scone against mid City
in cemsequenee of Ota granting of this Permit. A G
^t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
0 V 4, t'a kQ� 511) G
Re-roofs
Sigwu.of AppliuMContramr � Dam
RAZARDOUS IffA L S Type of Roof
Will the applicant or fu um Wilding mmpmtsorc Or Mrdle haudous mamrial
As defined by ft Cuperiject Municipal Code.Chapter 9.13.and the Health and Safety
sae.Section 25532(a)7All roofs shall be inspected prior to any roofing material being installed.
❑Yu Na
Will the applic to or future Wilding Occupant use cquip.ent a dcvlma which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air cawmminamas as defined bMy e Bay Ama Air Quality Management all new materials for inspection.
DisrictT
❑Yin No
I haw mad me haurdmu material requirements,under Chapter 6.95 of tits Calira-
niaHcellhkSar'cry COM,Smdmu25505.25533md75534.lundc wdthslfmc Wilding
lima net c mentiy haw a meant lime it 4 my m prusthility in Acidly the occupant of the
requ mentswhkh As Met mieaumm ofaC 'Ocamorocmpmcy. Signature of Applicant Date
All roof coverings to be Class"B"or better
I
wnerwautllbrtrnda col Dam'