05110129 CITY OF CUP
ERTINPERMIT
BUILDING DIVISION
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BUILDING ADDRESS: PERMITNO,05110129
22066 HIBISCUS DR
OWNERS NAME: PERMIT EHUE DATE
ODETTE & AYMAN ABUKHATER 12/13/2005
IJ; SANITARY NO. CONTROL NO.
ARCHITE VENGINEER: BURRING PERMITINFO
BLDG ELECT PLUMB rnMECH
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�oo LICENSED CONTRACTOR'S DECLARATION
81 boreby affirm Net 1 am licensed under Include.or Chapter 9(cro mommhg Job Description
with
So earn 70DO)ofDivialon 3 of the Business nM Professions Code.and my licene is
Inmllforeemdefract. ADD 152 ' (MS BATH, CLOSET) &
pd'�z Dunne awe Onto UPGRADE ELECT. PANEL
all
ll
Dun y Gamnnor
ARCHITECTS DECLARATION
l undewnd m Plots Nell he usc4 as Public rtenrds
=ad Licensed Professional
g OWNER-BUILDER DECLARATION
E r f I hemhy efrirm that I em exempt from the Comnamh License Law for the
0 O following won.(Sad.] Business,Business and Prolcim..Code:Any city ver county
S$ which regot.•Permit to carousal,ellen improve.demolish,or repair my annum
�t prim tar its issuance.also requires the applicant for such permit to file A signed statement
g e metboblicensed Final in@eprovisions ofthe Comncm„ UaafcI..(Chapter 9 Sq. Ft.Floor Area Valu -31p58
q (commencing wire Section 7000)of Division 3 of Me Business and Profession,Code)or
that he Is exempt therefrom and me bub fm the alleged exemption.Any violetfnn of
Section 7031.5 by any applicant for a permit subjects me applicant in a civil penalty of Ap/N N}� ber Occupancy Type
act mon than five hundred dollars(5300). 32 tl 0 2 V 2 . 00
❑I,u avam of Um pmpeny m my employm with n{es u tireb role compemtioa,
will do the work,and the.uucture Iran,intended of offered(anale(See.7040,Business Required Inspections
and property
h Wilds cede: ape Camuacmr,License Law dna or apply lf an owner of ��M� 9 P
and Poo who s,Ccs:The Germerton, rd L-cen Law
cons act
"ply i amen{e his
awn employm,provided thaamh improvements are notinlemded moBend fmssle If,
however.the building or improvement Is sold within oro)eu of compIruon.me.,.
builder will haw the burden of pmvin{that he did art Wild or improve for purpose of
sale.).
icy 1,ns owner of ct Sce.7property,,B exclusivelynd eonesnin{with licensed omm nes -
cAbmtna dproject(Sea.n ass Burin...andrrywhooui Cade:)The Canuaemrs tad
censentrdmact apply icas ownerofprepeny.wbo sedbuilds
Pr to
mamosesod. '��'��
who contracts for such pmjens with a contractor(s)licensed punuent to 104 ConOwtoh
0 Ion
mew.
❑lam exempt under See .B kP��Cfor�W�s reason
Own:i / Data a=—N-_f"r
WO0. SCOMPENSAT7ON DECLARATION
I hereby,Bir under.penalty of perjury one of Me following declanuoms.
1 have and will maintain a CeAfiats ofConmm m tall-imam for Wmkar'sCompmn-
wtion,u provided fm by Section 3700 of the boor Cade.(m Ute Performance of me
wank fm which Nis peril is loved.
❑1 haw and will maintain Workers Compensation Inmrmmce,as required by Section
3700 of the IaWr Code,for 0e performance of the work for which this permit is Issued.
My Worker',Compensation Insurance cannot and Polity number an:
Comer. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thnsection need not W completed If me permit I,forone nonmed damn($100)
or hag)
1 certify No,In me performance of the work for which this Permit It!wood.l shall not
employ any person in any man roan becmpe subject m me Workers`Compensation
Lawsof Ctliforie Pre ^�2�=^`
Applicant Nlr' sn
NOnCE 70/� CAIA:Ir,army penWng this Cenifis of of Labor Code,
you should
.J 0become subject m the Wohero Compensation a,thl provll"of the recd i Code,you mot
faMwlm comply with such provisions or mIr peril shall bo dcancd invoked.
�Nl CONS11UCf10N LENDING AGENCY
f+ I harebyliftr that Nen is•commuvimr lending agency for the pertorance of
ma work for which this peril is Wood(Seg.3097,Civ.C.)
Lender'sNwne ,
.7 z Lender.Address
U Q 1 minify that 1 Mw and this application and tum that the above information It,
U4!'. cora 1 agme in comply with all city and county ordinances and su ac laws relating an
Olr! building construction.and hereby authorrim representatives of thiscily W enter upon ft
W above-mentiomd property for inspection purpose,
LL (We)agree to sew.indemnify and keep barmless the City of Cupertino against
sup liabilities.judgments,costs and expenses which may In any wry scene against said City /
C) in LIICUuerace of Me NDwung of ERSTANDS s ismoil.
APPLICANT UN STADS AWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
(X I�I3/l�r Re-roofs
s45�re o(APpnceatrconteacmr DoT
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tiw applicant or future building occupant tore or handle busrdous material
an defirmtl by the Cupeniw Municipal Cale.Chapter 9.12.and rime Health and Safety
ale.Section 25532(.)] All roofs shall be inspected prior to any roofing material being installed.
❑Ya IANo
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hevudoa air contaminants unt
deed by Ne Bay Am,Air Quality Management all new materials for inspection.
iwicl7
❑Yea 19'N�U
l haw mad the hssadeus maleriab requimmems under Chapter 6.95 ofine Califor.
nu Halm&Sefc,yCadc,Seek.235(13.235J3 wW25570.1 andcrnand Nei if me building
dm rot currently have a annual.mu It is my responsibility to truly the occupant of me
requirement;which ratio W met prior m issuance of a CcrificAm ofOe'UP y, /Gr Signature of Applicant Date
l a All roof coverings to be Class "B”or better G
Owner or Authorized agent am