03120086 FCI TY OF CUPERTINO x 7 �°";vw�
BUILDING DIVISION PERMIT CONTRACTOR TNFQRMATIQN
IRUILDINGADDRESS: HAMID ABTAHI PERMIT NO.03120086
OWNER'S NAME: PERNIM MUE DATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: _ BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300 LICENSED CONTRACTOR'S DECLARATION O O O O
1 hereby arr m that 1 am licomed under providers of Chapter 9(commencing Job Description
with Sccdon7q )of Division3ofthe Osis and Pmfeuium Code.armmyliccnwis
iiZ niRace and effect.
499 SQ. FT. ADDITION
viniton full Class Lic.N
Da¢ Contractor
e� ARCHITECTS DECLARATION
y U I undemand my plana shall he used as Public mcnrds EM
;0f, Licensed Profcasionel
OWNEm axe AER mDECLARATION
2 I hereby.(Seto Net I am exempt from one Canranor's Licence Taw fort c
oO
which requires
(Section 7 emir t. he,.
and Pmfc.cions Code:An city nr mum
which rcyuira a pcmtit m cnnnrucL elms imprnw,demolish,or repair any smucm i -
_iy poor m itsissumm.also requires on,applicant for such Permit file nail^ed summed.
that he is licensed pursuant the provisions of one Comra=mh Lisnm law(Cham 9 q' t. FIO a. I Valuation
(commencing with Scotian 711(10)o(Division 3o(the Business and Profasinna Cade)or
Not he u exempt therefrom and the bub for the alleged exemption.Any violation of
Section'ID31.5 by any applicant for a permit subjects the applicanuo•cavil penahyof 3'A J31`b0erpp Occupancy Type
not dome than five hundred dollars 0500).
❑I,as owner of the propeny,or my employees with wages as their sale compensation.
will do Ne work.end Ne ma.mm is not intended or offered for sale(Sea 7044,Business
and Pmfeuians Com:The Comncmes License Law dao nal apply man owner of Required Inspections
properly who builds or impraves thereon,and who duessuch work himself or through his
own employees,provided that improvements are not intended at offered Russia.If,
however,sae building or improvement is sold within one year o(completion,theowner.
Wild.,will have Or Wrden of proving mat Im did not Wild or improve for purpose of
sale.).
❑1,a owner of the progeny,am exclusively contracting with licensed contractors m
construct the project(See.7044,Business and Professions Cade:)The Comracmr's I.J.
come law does not apply to an owner of property who Wilds or improves themon.and,
who contracts for such projects with a cemnctor(s)licensed pursuant to the Comma lm'.
License Law.
X r]1.
Ownp(1'ZaemLpa�Jt under.
B Ar PaC(`orrthis ma
nn
�� -710
Date
�ORKER'SC �� DECLARATION
1 hereby&loan under penally of perjury,one of dm following decimation:
I have and will mainuin m Certificate of Coaenue self-iaum for Worker's Compere
scion,a provided for by Section 37M of the labor Code,for the performance of the
work for which Nis permit is issued.
❑1 have sad will maintain Worker's Compensation Insurance,a rrquired by Section
3700 of the labor Code,for the performance of Ne work for which this permit is ianed.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier, Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSU RANCE
(This Saban need not W completed if be Permit is Room hundred Out.ISI W) '
or less)
1 ecnify that in the performance of the work fa which Nis permit is issued.I shall not
employ any person In any manner an a or become subject e Has Workers Compenssdon
Laws of California.Date
Applicant .
NOTICE TO APPLICANT,IL after making this Cer ificam of Exemption,you should
became mhjat to the Worker'.Compensation provisions of the Labor Code.you most
.J O foMwith comply with such provisions m be de
Nis Permit shallemed revoked.
'Z r CONSTRUCTION LENDING AGENCY
.N-t( Ihereh (firm Nat Nem its construction lending agency dor the~ hereby g g y' perfurmenee of
UJ Ito work fur which this permit is issued(Sec.J09'1.Civ.C.)
W E Lenders Name
P.Z) z lander'.Add.,
U Q 1«oily dust 1 have mad this application and sou Nat Ne shove Information is
U, P aorta,.I agora to comply with all city and county oto rome s and sum laws heading to
0U building construction.and hereby anthodre representatives Of Nis city to enter upon the
W
above-mentioned property for inspection purposes.
(We)agree to saw,indemnify and keep hamaleas the City of Cupertino against
tr N liabilities.judgments.costs am expenses which may in any way acme against aid City
U 7 in conmgmnec of Ne granting of this permit.
�7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
sou Cf REGULATIONS.
Re-roofs
Signature of Applumm/Carmacmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dm applicem sir forum building acupanumm or hanJle harallous materiel
as canned by the Cupertino Municipal Codc.Chapter 9.12,and the Health and Safety
Code.Section 25532(g7 All roofs shall be inspected prior to any roofing material being installed.
Ya CXNu
Will Nc eppli=&^ter ffuCmm building aronpantnmequipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
II hanumus air conumina^u a mrnOd by the Bay Arca Air Quality Management all now materials for inspection.
Inr,7
❑Yes No -
IhavemNthehmammsmamrisbmpurtar .sunder Chapter 6.95 of the Calif.,.
nia HcalthGSafely Cwlc,Sadmu25505,255)3and25534.1undcrsundtha ifthe Wilding
doesnot currently have a motor,that it b my responsibility to andly the occupant of the
req ' mcnuwh. roustbemclpno anaencenirteamerOceepanry. Signature of Applicant Date
11 All roof coverings to be Class"B"or better
0 ncr r anNmi'rcd tcDots g
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform
AAll the work authorized by this permit
B. _ A portion of the work
C _ None of the work
If B or C is checked, complete 2 or 3 below.
2. 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. _ I 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 mustbeon 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(reverse side).
Property Owner's SigriaturR' %/��J w �" L%�^?C Date: p
Job Address: �d 6� b���V-/ vJ �r. Permit# 1,;20o
AU chanties to the information5�5 provided on this form shall be submitted to the City of Cuyertino Build
Department.
City of Cupertino Building Department
aOF 10300 Torre wenu
CU PERTINO Phone: (406)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,yourself 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 Califon-da,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 carry 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 peratit will not be issued until the verification is returned.
Very truly yours,
Building Department,
City of Cupertino
Printed on Recycled Paper
CITY OF CUPERTINOA`C5ORnuTLDTNc DTvlsloN PIRMIT CONTINFORMATION: '' - `
4'e1uV_3 .«��' .t9A `4 B5}i"$1"i<San�� V' L,.w-^d'•nHi3' ��%
BUILDING ADDRESS: PERMIT NO03120086 3120086
OWNER'S NAME: PERMIT ISSUE DATE
14PONE: SANITARYNO. ri� CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
] 0 0 0 0
YOo LICENSED CONTRACTOR'S DECLARATION
rd I hereby affirm that em licensed under provisions of Chapter 9(commencing Job Description
with Section 7")of Division 3 of the Busirw and Prufcsslons Code,and my license is
p iforce andeffect.
D N incrue
Z Dow clan 499 SQ. FT. ADDITION
Loo.o
C J Datc Contractor
eG F ARCHITECTS DECLARATION
y� I understand my plana shell W..do public record.
�6
MLicensed Professional
OWNER-BUILDER DECLARATION
i X 1 hereby affirm that I am exempt from the Contractors License Law for the
00 rnllowing moon.(Section 11131.5,Business and Prefeedons Code:Avy Oily ur c my
S� which requires a permit to construct,alter,improve,demolish.or repair any armurt
_Zx< poor to its issuance,also mquims the applicant forsuch permit to rile a signed sutemem
FO that he is licensed pursuant to the provisions of the Contractor's License Law(Chapmo9 Sq. Ft. Floor Area Valuation
(commencing with Section 1Oat)of Division 3 of It Business end Prof.inns CMt)or
$
that he is exempt there from and the basis for the alleged taempomr.Any violation of ne�,p
Section 1031.5 by any applicant for a Permit subjects the apP[Mcu to a Civil penalty of 00 Occupancy not more than five hundred dollars($500). 3'ABBi"NDI�$erp y 71�pe
0 1,ar owner of the property,or my employees with wages u their sale compensation,
will do the work,and the swctom isnot immmded or offered for sale(Sec.IDN,Business
and Professions Code:The Contractors License Law dao or apply to an owner of Required Inspections
property who buildsor improves themon,end who doessuch work himself or through his
own employees,provided shauuch improvements se,not intended oroffered for We.If.
however.the building or improvement Is sold within one you of complcden,the owner.
Wilde,will have Ne burden of proving that he did not Wild or improve for purpose of
sale).
❑1,as owner of the property,am exclusively contracting with licensed convotors to
construct the eject(Sec.ID1d,Business and Pretenders Code:)The Contra set LL
terse law does not apply to an owner of property who Wilds or improves Merton,and
who controls fonuch pory,3 the cemnaor(s)licensed initiation to the Contractors
Leon.La
❑lam ex in tinders ,B&P C for this rtnon
0. 1l Data
I, Q
�I /X iKERS COMPENSATION D�E6{.ARATION
I hereby affirm under penalty of perjury f f the fallowing declarations:
1 hats and will maintain a Certificate of Consent o sel6imum for Workers Crimper.
anion,as provided for by Section 3100 of the Labor Code,for the performanee of the
W
ork for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance.ss acquired by Section
3100 of the labor Code,for the p oformanco of Ne work for which this permit is Word.
My Workers Compensation Insurance carrier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS*
COMPENSATION INSURANCE
(Thin section raced not bo completed if the Permit is forint hundred dollen(SIM)
lir lcsa)
1 certify that in the performance of the work for which this Permit is issued.I shall not
f employ any person in any manner so as lac become subject to IN Workeri Competition
Laws of Celifoome.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation previsions of the IaMr Code,you must
Qz foMwi th comply with such provisions or this permit shall M d.emcd revoked.
z " CONSTRUCTION LENDING AGENCY
I hereby brim Nat them is a construction lending agency fm dm performance of
!Yi the work for which this permit is issued(Sec.3091 Civ.C.)
DO
ca Lender's Nam.
D z Lenders Address
U Q 1 certify that I have read Nis application and sum that she above information is
Iy P correct.1 gone to comply with all city and county ordinances and state laws relating to
(]U building convection,and hereby amounm mpresenulivee of this city to color upon be
In abovetme judgments,
ud and property for inspection uss pury.sea
C (We)agree tri save,indemnify and keep harmless the City or Cupertino against
reg in
dgme the grassing expenses which may in any way acttuc against mid City
U z m cense ANT or UNDERSTANDS
of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON•POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
nature orApplicart/ConorenclurHAZARDOU �� Date
HAZARDOUS MATERIALS DISCLOSUR Type of Roof
Will the a Cu,nl or factum building k.Clupi smm o.ha;�the Heartens mammy
u defined by the Cupertino Municipal Code.CNpmr 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
F7 Yes ❑No
Will the applicant or mtore building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hanrdnus air contaminants u defrc l by(be Bay Area Air Quality Management
string all new materials for inspection.
C3 yes 0N
1 hoc rail the hasaNrms materials requircmenls under Chapter 6.95 of the Celifor.
his Hca W&Safety Cade,Sections 25505,25533 and 25534,1 onderstand that if the Wilding
dors not currently hoc a Cram,that it u my responsihilily to notify dC omupbnt of the
mquiacmcnts which must W mel prior to issuance of a Ccnlf!M1 Occupancy. Signature Of Applicant Date
o n atithnnaeaas.nt oars All roof coverings to be Class"B"or better