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CITY OF CUPERTINO
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BUILDING DIVISION PERMITf,��
BUII 1T IInIFsRANAPERMIT
DA AVE
TBD — TO BE DETERMINED
No.
07110039
OWNER'S NAME
PMUAI T ISSUE DATE
HAMID GHAZVINI
01/15/2008
PHONE:
SANITARY NO. CONTROL NO.
ARCI-0I=fENGINEER:
- -'
BUILDING PERMITTNFO
Bl DG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirms that I am licensed under provisions of Ouriner 9 (commenting
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
DEMO SINGLE FAM . RE S
in full force and effect.
L.Iccnse Class Lie. I
Date Contractor
ARCHITECTS DECL.ARAT10N,
I understand my plans shall be used as public records
licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct alter, improve, demolish, or repair any structure
prior to is issuance, also requires the applicant for such permit to file a signed statement
to the of der Contractors License Law 9
Sq. Ft. Floor Area Valuation .
that be is licensed pursuant provisions (Chapter
70DM Division 3 the Business Professions Code)
$ 4 5 0 0
(commencing with Section of or and or
that he is exempt therefrom and the basis for the alleged exaoption. Any violation or
3 5 717 0 5 6 7� 9' Number
Occupancy Type
section 7031.5 by any applicant fora pmWt subjects the applicant to a Civil penally or
not more than five hundred dollars (SSOQ).
❑ I. as owner of the property. or my employees with wages as their sole compensation,
Required Inspections
will do the worn, and the structure Is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
awn employees, provided that such improvements are not intended or offered for Sale. If,
.
however, the building or improvement Is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
Icy)
L as owner of the property, am exclusively contracting with licensed contractors to
nsuw the project (Sec 7044. Business and Professions Cade:) The Ctimiu toes Li.
tense Law does not apply to an owner of property who builds or improves thereon, and
.
who conuacts for such projects with a contract or(Q Iicwsed purswnt to the Conuactors
License Law.
❑ I am pt u der See. B & P C for this reason
,
_
Owner f I- a -()
ORI 'S COM SA ON DECLARATION
I hereby arm under penalty or perj one or the following declarations:
affirm
❑ I have and will maintain a Certificate or Consent to self -insure for Wortcrs Compen-
sation, as provided for by Section 3700 of the Labor code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performanxe of the work for which this permit is issued
My Workers Compensation insurance carrier and Policy number are:
Carrier. Polley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Kris section need not be completed if the permit is f« one hundred dollars ($100)
or less.)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manncy so u/(o beeom nicer to the Workers' Compensation
Laws of ice. DaJ� r G, �- YZ
'�'� � t 1
9,CANT:
NCTAppliarrlf
after malting to of E
NOTICE PLIC If, g thrice CeniGata of Exemption, you should
become subject to the Workers Compensation provisions or the Labor Code, you must
' forthwith comply with such provisions or this peanid shall be deemed red. volm
1
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit Is Issued (See. 3097, Civ. C.)
'
Lendcrs Name
,
Lenders Address
I certify that I have read this application and sole dud the above information is
correct I agree to comply with all city and county ordinances and state Ines relating to
ibuilding construction. and hereby authorize representatives of this city to enter upon the
above -mentioned property for Inspection pub
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities. judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting or this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WrrH ALL NON -POINT
Issued by: Date
S REGULATI S. -
Re -roofs
-
Type of Roof
r r
sgnature or fiarnUContractor
HAZARDOUS MATMUALS DISCLOSURE
WIII the applicant or future building =Upant store or handle hazardous material
as defused by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
-
Code, section 25532(a)7
Yes KN-o
All roofs shall be inspected prior to any roofing material being installed.
p
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or rutuut+++¢¢¢ building occupant use equipment or devices which
emit hazardous air contamusprtt as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes ❑ No
I have read the ltarardous materials requ mmanu under Chapter 6,95 of the Califor-
ida Health & Safety Cale, Sections 25505, 25533 and 25534.1 understand that If the building
does not cuncnoy have a tenant that it is my responsibility to notify the occupant of the
roquirernerasxhie m be met prif a crstificalc or occvpanry.
Signature of Applicant Date
+ —�
All roof coverings to be Class "B" or better
� Data'
Owner or authorvrtl agent