03100062 CITY OF CUPERTINO
"p, a =•s;r
BUILDING DIVISION PERMIT PCONTRACT0' INFORMATION.
BUILDING ADDRESS: TAGHI MALEKSHOAR PERMIT NO
O3100062
OWNER'S NAME: 10555 GASCOIGNE DR PERMIT ISSUE DATE
JNE: SANITARY NO. CONTROI,NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BILDGn PLUOMB MEC11
±oo LICENSED CONTRACTOR'S DEskma of bar
0
eUC ON
1hefchyarfirmmatIam limn.Buinssnd Professions
Code. vmylicenang Job Description
�c with Scarce and effect.Division Jof Bc Business and Pmfcssions ends.and my license is
mrnumreeanderr"'' SEWER REPAIR
? Liam Class Conti O /
�Fw Dam.Contractor �A
ARCHITECTS DECLARATION 2
1 w u I undersand my plans shall be used as public records
Licensed Prnfessionol
.Q5 OWNER-BUILDER DECLARATION 3
a X 1 hereby Affirm that I am exempt(rum the Contractor's License Law for the
00 following reason.(Section 7031.5.Business and Professions Code:Any city Or county
i m� which requires A Permit us construct,alter,improve.demolish,or repair any stmictum
uai prior to its issuance.also requires the applicant for such Permit in file a signed statement
cap
that he is licensedpursuanunthcprovisionsortheContractor'sLicenseLaw(Chapter9 Sq. Ft. Floor Area Valuation
EL (commencing with Section 7")or Division S of the Business and Professions Code)or
3 Nat he is exempt thciefrom and Be bazu for the alleged exemption.Any violation of 37523006 . 00
Section]031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of
car me.than Five hundred dollars(s500). - APN Number ,.._ Occupancy Type
❑I,as owner of Be property,or my employees with wages az their sole compensation,
will do Be work,and Ne suuaum is not intended moffered(or sale(Sec.7014.Busircv
and Professions Code:The Conusn.rs License Law docs not apply to an owner of IL ections
property who builds or impron ,memon.and who doessuch work himselfor Brough his 202 - UNDERFLOOR PLNBING
Own employees,provided that such improvements are not intended oroffered for Sale.If, 301 — ROUGH PLUMBING
however,th,building or improvement is sold within one y,at of completion.Be owner-
builder will have the hard,.of proving Nat W did our Wild or improve far rmprom of 5 07 - FINAL PLUMBING
sale.).
❑I,as Owner of the pro eny,am exclusively contracting with licensed conuselms to _
construct she project(Sec.7044.Business and Professions Code:I The Contractor's Li.
ease Law docs not apply to an owner of property who Wilds Or improves d¢reon,and
Io contracts for such projects with a contramm(s)licensed pursuant to the Contractor's
c.Lew.
lax, der See. ,B&PCfor
0 n Data PC m azo.
WORKE PENSATIOND ATION --
1 hereby affirm under penalty of perjury one of Ne fallowing declarations:
I bane and will maintain 4 Cenificam of Consent to self-insure for Worker's Compen-
sation,az provided for by Section 3700 of me Labor Code,for Ne pedmrnahme of the
work for which Bis permit is issued.
❑1 have and will maintain Wwker's Compereadon Imurance,az required by Section
l]00 of Ne Ubor Cade,for Be performance of Ne work for which Bis permit is issued.
My Workers Compensation has
carrier and Poliq number am:
Carrier: Policy N., _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Nis section need not beemadeed if the Permit is for one hundred dollars(S 100)
or less)
1 ecaify Nm in the perfonnanc work ror which this permit is issued.I shall not
emPloyany pe t am Asnazrd McumA subject toU Wmlmn'Comprnndon
APPa.. C -
N TO APPLICANT:If,aper making this Certificate of Exemption,you should
We subject to the Workers Compensation previsions or Ne Labor Code,you mus
,Z forthwith comply with such powisinas or Nis Permit hall be deemed mvokcd.
Z:O CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat Ncrt is a eomtruminn do,pc
lending agency for do, of
1' IW work for which this permit is issued(Sec.3W7.Civ.C.)
11 Lender's Name
S'z Lenders Address /^\
J Q 1¢nee that 1 banply read this application and sura that and
above ws oulation is / A `-
i t✓ correct 1 agree ct comply with all city and county oealin,of and cram laws relating to v —
V Iflionngconswction,any forim,tborimrposeunutives of Nis city to enter upon Be
IL above-(We)Occ!are to Sany find emnify an purposes.
IL (We)agree to save,indemnify and kap harmless the City of Cupertino against
N liabilities,judgments,costs and expenses which may in any way accmc against said City
Jz meonsequenec of Bc granting of this Permit.
^ APPLICANT UPIARSTANDS AND WILL COMPL WITH ALL NON-POINT Issued by: Date
SOUR CFjpE TIONS. `'
50�
si .1 APP umulConusela C Re-roofs -
am
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hmodous material
asdefined by lW Cupertino Muni,, Calc.Chapter 9.12,and the Health and Safety
swe.Section 25532(a)?
❑Yea Ne All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
it hazardous us air c.ntaminanu aydcfncd by the Bay Arca Air Quality Management all new materials for inspection.
Ulricr? G N
❑Yes Nu
I have read On,hvaNsws materials mqumemeOS under Chapter 6,95 Attic Califon
nice HcalN&SafctyC c,Scctiom 25N)5.255JJ anJ 255}4.1 understand Nsir Bc Wilding
dors noLL'unen rte a tenant Nat it is my mxpensihility m notify the u:cupanl of Be
mqui�Or` _It must W met prior u issuance of a Ce ficam of at, c
9�o Signa[ureofApplicant Date
caner or authonred a,cnl - D,m All roof coverings to be Class "B"or better
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform: .
A. All the work authorized by this plbeloiT-
2.
ECETV�i
B. A portion of the work OCT 0
C. None of the work 9 2003
.
If B or C is checked, complete 2 or 3 A state licensed contractor will be hired to do:
A. _ All of the work
B. A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
. 3. _ 1 will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City . Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(revere de).
Property Owner's Signature Dat Y�'
Job Add s: /d 5�X � < C�i 0. - Permit#
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
City of Cupertino Building Departmen
CITY Of 10300 Torre A, nu
C U P E RT 1 N 0 Phone: (408)777-322
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit. Building permits are not required to be signed by property owners unless they are
personally performing their own work. If your work is being performed by someone other than yourself,you
may protect vourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family,and the work
(including materials and other costs) is$200 or more for the entire project,and such-persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding,federal social
security taxes,workers compensation insurance,disability insurance costs,and unemployment compensation
contributions.
There may be financial risks for you if you do not cavy out these obligations, and these risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish,the U.S. Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed contractor or
subcontractor, only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit,erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License
Board in your community or at 1020 N Street,Sacramento,California 95814.
Please complete and return the enclosed owner-builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
Building Department,
City of Cupertino
Printed on Recycled Paper
CITY OF CUPERTINO 03
OF REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN #
Building Address:�v
GAsco / he ) .
Owner's Name: ---A G/f.T — MAsE
7400/ Phone kW o
MOLD_ e
Contractor:
awn e� O! F/oAs'c Phone(L/e$�72 j 8s ys License
Contact: Phone: Cupertino Business License #:
Buil g�Permit Info:
ld Elect ❑ Plum
Q!
s option:
Residential Commercial ❑
Cost of Project:o,a i DU
Qty. i
A 1' ab Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Rei of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWS VCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
231-7