04020033 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT s CONTRAGTQR INF,�ORM ATION A
BUILDING ADDRESS: PERMIT NO04020033 4020033
.R'S NAME: PERMIT ISSUE DATE
JAVAD ZOLFAGHARI
ONE: SANITARY NO. CONTROL NO.
ARCHITEC IENGi NEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
r___10 0
aoo LICENSED CONTRACTOR'S DECLARATION
til F❑ I hereby arrirm that I am lieensed under provisions of Chapter 9(commencing .Job Pe$Cription
iW with Swtion]IXYJ7 ofDiviaionJofthc eminua and Pr9fcssinnsCode.andmyli¢nx is s(^/q
��„ in felt to.and teff.,.
License Class ADD 1214 SQ. FT. '�•�-/�/p�/77�//
j ? n L .'cN
ZFa Dow Cmdaclar
ne ARCHITECT'S ami DECLARATION �®
1. 1 unmrsmnJ my plans still W used u public mcorm /e�
J y U /�/_
;off LiccnuI hereby Tonal /
3 OWNER-BUILDER DECLARATION
a O I hereby alarm Second
I am exempt from tpr Conlns Cod License Any c Law for the Of
p o following smog(Semon RIJL&Business and improve.
de professions Code:Any city s county
m which mquissu a permit m ennmrom,alter,improv,demolish,ri weir any structure $i c;nnnn
prior roits issuance.also requires the applicant for such acnniuo rile asigned summcm
'£s< that he is licensed pursuant othe provisions ofthe Contractor's License Law(Chep¢r9 Sq. Ft. Floor Area :97fin Valuation
y l-$ (commencing with Section 7")of Division 3 of the Business and Profusions Code)or 9
- Nat he u therefrom add therefroand the basis for Ban m1a,d exemption.Any violation of @`�-
Section 7031.5 by a"eppliruo for a permit subjects she applicant to a civil penalty of 3-ATNMf ber0 0 't=:'OCCUpancy Type
not mom Nan five hundred delta.(35001.
0 I,as owner of Ne property,or my employees with wages as their sole compensation,
will do thework,end the structure isnotimended W oRemd for sde(Sec.70".Business; Required Inspections
and Profound.Code:The Ccentsuum's License Law does not apply m an owner of q p
property who builds or improves thereon,and who dma such work himself or through his
own employees,provided that such improvements art not intended or offered for sale.IL
however,the building or improvement is sold within non,year of completion,the owner.
builder will ban the burden of proving that he did nut Wild or improve for purpose of
aAleJ.
I,as mvrcr of the property,am ea bisivcly concocting with licensed mnoamora in
construct Ne project(Sec.7014.Business and Professions Code:)The Co mumeas Li.
we law does not apply to an owner of property who Wilds or improw.s thereon,and
who contracts for such projects with a contractor(s)licensed pursuant In the Cpnwnars .
License law.
U
laden TopaCrSe. .B&PCfor,�laam on
` Dam 0
WOR cER'S PENSA 'NCLARA gg\\
1 hemby afBsm uge ty of perjury one of the folbw�'ia64Rladatioim
I haw and will main Tin a Certificate of Comem to ae8-insure for WorkersCompcn-
nation,as pmvidcd for by Section 3700 of the Latter Code,for the performance of the
work for which this permit is issued.
0 1 have and will maintain Workers Comperaation Irtsurentt,as mquirod by Section
3700 of the Labor Code.for the performance of the work for which this permit is issued.
My Worker's Compensation Insuram carrier and Policy number am:
Cartier. Policy No.:
n CERTIFICATE OF EI(EMPTION FROM WORKERS'
COMPENSATION INSURANCE
maiaxetion need not W completed if the permit is for tax hundred dollars(SIM)
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 manner x as to become subject to the Workeri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:V.after making this Cenificam of Estimation.you should
become subject m the Worker's Compensation provisions of the labor Code,you most
.JO fonhwidl comply with such provisions or this permit shall&deemed revoked.
Z CONSTRUCTION LENDING AGENCY
(r I hemby aRran Nat ft.iso...find landingagcncy for Bm parurmance of
!Yi Ne work for which this permit is issued(Sec,3(N],Civ.CJ
W Lender's Name
D Z Lender's Address
U r 1 ttnee that 1 have read this application and sus Net tic above information is i
It,0 U caned 1 agree ct comply with y city and representatives
nNinantts and slam laws miming to
p U iWw-gconscoNanarty hemby authonp rposes. utivcs of this city to cater upon the
r W aWn-mentioned ree I...roperty for indmnify an nd ker,hs. 1)
Fy liabilide.judgmcnts,castsandespeyses which may I.arywayd,iss the raanso.gof eiestsad City
rore,against
U z in eanuquenec of the B of Nis permit.
APPLICIA I STANDS AND�W LL COMPLY WITH ALL NON-POINT Issued by: Date
So,
(:ER LATIONS. V G -- O3 �Sp
Re-roofs
at re of Applic' Date
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or Future Wilding accupam mom or handle hanNous material
dcnncd by Ne Cuper(ine Municipal Com,Chapter 9.13,and the Health and Safety
e.section 25532(a)] All roofs shall be inspected prior to any roofing material being installed.
❑Yea Irl No
Will the applicant or future building occupant ax equipment or devices which If a roof is installed without first obtaining an inspection,I agree[o remove
mit haiardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Digital
❑Yea KIN.
I have real Ne has Mousmawrials mquimmenu un&r Chapwr6.95 of thc Califon
nia Health& uom 25 and35534.1 amm�und Nutt do Wilding
dma eve a Tena at�i' rlibiliry m notify lM
part of Ne
item u�' tan thi racenificamnrati paney. Signature of Applicant Date
03 a2S O
caner r apmnri. sen Dam All roof coverings to be Class "B"or better