04050017 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C0�ITRAGTQR`INFQRMAIQN
,.o t auk ,
BUIL DING ADDRESS: AC CONSTRUCTION P�"MIT" 4050017
41 c; TIENEY CRETEEK PT,
ER'S NAME: PERMIT ISSUE DATE
MAJEED NOVBAKHTIAN 1719 QUADALUPP, AVE Q-5 /04/2004
ONE: SANITARY NO. CONTROL NO.
408 374-1497
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION Job Descrition
I hereby affirm Thal I am licensed under previsions of Chapter 9(commencing P
with Section]0!X11 of Division 3 of the Business and Prefrsdnns Cade.and my license is
in fan fn=and effect. REVISION--IN HOUSE USE ONLY
D q i Liecrx Class Lic.g
Z- Data Common, NO NEW PERMIT ISSUED/ORIG. #►04030035
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
a.1yU
Lkcnsed Professional
OWNER-BUILDER DECLARATION
+� 1 hereby,Ilion that 1 satm exempt from the Conlncro Code:
: c taw for the
i p O following mason,(Section R axon Business and Profc,moll h.or Any tiny someone
whichrequires;,Pewit minus be,alesimprove,h Permit! ore a signed
ig anyummer,
pilar,its I licensed
p also requires pro applicant of fief sucC.p nscom'w fit a aLlw(amxmCnl
rz< thaterebuccnxdFuwmstothe provisionsofthe Ca usinessandProfLaw(Chapter9 Sq.F[. Floor Area Valuati 07
aEf�$ (mmmrncing with Section7000)and
of Division 3 of me cited Business and on.Any
Cade)ladon of
..
that io is 31.5 b any applicant
li and Ne buss for the cts do, exemption.t.Any violation of
Section 7031.5 by any applicant fon Permit subjects the appliwtuoacivil penalty of pith Number Occupancy Type
nor martthmfive hundred dollars(550B). 34248021 . 00 '
❑I.u owner Ofthe pmpcny.w my cmplo co with warm u Meir mle eompe$lion.
will dothc work and theswcmm is notinmrded ora@red foraale(See.TDaa,Businev Required Inspections
and Professions Cade:The Cowxmh Lim.Law docs non apply m an owner of 9 P
Facially who buildsorfmproves thereon,end whadoes ouch wrrkhimxlf ar through his
own employees,provided that such improsemenu are not intended oro@red fm sada It. /y
Wilderhowever.the building.,ft or ofproving xthe di in aro year of c prove foron.the aweerf \
hwill bass me burden improvement midol within
not build m improve for puryose of
sale.). \�l
.as awncr of the progeny.em exclusaxly contracting with licensed coneRno s no
mnswcn me pmjen(Sec.]Odor Businw atb Professions Code:)The Conuecmrs l;- V t�
Cnse Law docs at apply m an awns of Forlornly who Wilda or improves Ihermn,and ria-
whocrnuacufor tytm(sI licensed pursuant us live Cunuacmra
Lkcn
tem amp rSec. .B A,P C for Nis
Da
WORKERS COMPENSATION DECLARATI
I hereby Caftan under penalty of perjury are of the foil mg dalarations:
I have and will maintain a Cenfficam afconsem m self-insure for Waters Campcm
utirn,as provided for by Section 3]00 of the ISWr Code.for the Performance of de,
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as sequined by Section
37W of the Lamm Coal far the perforromem of the work for which this parent is issued.
My Workers Compensation Insurance carter and Policy number are:
Grier. Policy No.:
CERTIFICATE OF FXEMP71ON FROM WORKERS'
COMPENSATION INSURANCE
(Thuxmion need not W completed it the Permit Is for one hundred dollau($1111)
or less)
I unify that in the reoformaxc of the work for which this Pewit a issued.I shall not
employ any persun in any manner so M m became subject to tha Workers'Compensation
Law,of California.Data
Applicant
NOTICE TO APPLICANT:If.after making thu Certificate of Exemption,you should
become subject to the worker's Compensation provisions of the Labor Code,you muss
.JO forthwith comply with such provisions or this lermiuhall W deemed rtmkcd.
Zo CONSTRUCTION LENDING AGENCY
(..14 I hereby affirm that Vert is a commuction lending agency for the Pcrform Lea of
C> the wart far whim this Permit is issued(Sec.309].Civ.C.)
VA 0 Landers Name
D.. Leaders Addy
V C) 1 certify that I have read Nis eppiic.ion and sum thn the above information is
C) cows.I agate m comply with all city and county oNinances and sou sews r lasing e
Wove--cons ted pro ert hc¢my auNodre rtpresenuurs of this city w enter upon tie
�tLl aWucmWe))', L.xxwina1W ccdonpurlwses.
(We)agree ,Cavei pensee hickharmless nhcyse of against
tsagainst
.Fr(4q limili tourcan dexpensearit. mayirsa`way eccmc ageinstsaid City
(„) PLICAenteC N TAN of this Pewit.
" APPLICA N STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC - G ATIONS.
Re-roofs
naw APplic,nVConwcmr t
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building=upset note or handle hamum us material
fmcd du Cupertino Municipal Code.Chapter 9.12.and the Health and Safely
.Sectionby 25532(,)7 All roofs shall be inspected prior to any roofing material being installed.
El Yea V4.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
mit hazardous air contaminants u defined by de Bay Arca Air Quably Management all new materials for inspection.
District?
❑Yes PINo
1 have read the hoardsmwas materials requiremcnu under Chapter 6.95 or the Califor.
ria Neslth BSafery Code.Sections 25505.25533 and 2553a.lwbcrsmnd matdde ilding
dors not cuwnti ponsihility m notify Uc oceu n of me
uquimore. tehmu W tpdorwissuarm raccnfficamofoccup Signature of Applicant Date
agent Date All roof coverings to be Class"B" or better