04040175 ' CITY OF CUPERTINOu^ :1sa°3x'sw4s,% s ' r ye `F� M"I.'' 'I `t:s
BUILDING DIVISION PERMIT CONTRACTO INFORMATION"^
BUILDING ADDRESS: VAHEED ZOLFAGHARI PERMIT N004040175
10781 JOHNSON
OWNER'S NAME: PERMIT ISSUE DATE
VAHEED ZOLFAGHARI 04/27/2004
ONE: SANITARY NO. CONTROL NO.
ARCHITECrIENGINCER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
900 LICENSED CON'nRACTOR dunderS—DECLARATION
hap Job Description
uuw 1 hereby affirm that 1 am fdo Bd under provisions o Chapter 9(commencing
SZ� with Season ndeffecDivision]of NC Business and Pmressinnx Code.and myliccnrcis
"`o% mmutomeanderten. TEMPORARY POWER FOR .ADDITION
Gn? License Class Lic.g
n�� Dale used as public
/
ARCHITECT'S DECLARATION 9
a 1 undcrsunJ my plans shall IDI used as public rcnxds
,aD �y
g a0 y Licensed Pn,ressinnal
S OWNER-BUILDER DECLARATION
qv a 5 1 hereby affirm that I am exempt from the Contractor's License Law for the
00 following region.(Section 7131.5,Business and Professions Code:Any city Or county
i m which requires a permit m ennstrum,alter,improve.demolish,or repair any mrucure $500
e¢i priorm its issuance.also requires the applicant for such permit to rile asignedsutement
'hat he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq. Ft. Floor Area Valuation
yFC (commencing with Section 7(00)of Division 3 of the Business and Professions Cale)or
y
that he is eaemps therefrom and the basis for the alleged exemption.Any violation of oo..
Section 7031.5 by any applicant for a permit subjects thapplicant ea
e applicano s civil Ftly of &_ er00 Occupancy Type
not more than rive hundred dollars(S500).
❑ I,as owner of the property.or my employees with wages as their sole compensation,
will do the work.and the structure is not intended or offered for sale(Scc.70a4,Business
m
and Prcasions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves Nercon,and who does such work himself or Borough his
own i mployw,provided that such improwmenu arc not intended oroRered forma.It.
however,Be,building or improvement is sold within one year or completion.Ne owner-
builder will hats the burden of proving that he did not bei Id or improve for purpose of
sale.).
1,as owner of the property,am exclusively eontrmting who licensed contractors to
c mtroct the project(Sec.7044,Busm=and Professions Code:)The Contractor's Li.
ccosc Law does not apply,o an owner of property who builds or improves themon,and
who contracts for such pro with a can
tran or(s)IiccnaedpuNuanIL the Contractor's
License Law
❑I cm ticr5ec. _ B k PC for this noon
Date 0
-2a
WORK' CMPENS OND ATION
1 hereby at under penalty or perjury,one o e following declarations:
I has and will mainuin a Certificate of Comer to self-invert for Workers Compmr
S."
as provided for by Section 37(3 of the Labor Code,for the pcommance of the
So for which his permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Calc,for But performance of du work for which this permit is issued.
My Worker's Compensation Insurance camer and Policy number aa:
Carrier. Policy N.,
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becomples d If the Fermi,is for one hundred dollars(SIp0)
or less.)
1 certify that in the performance of the work for which,his permit is issued.I shall not
employ any person in any manner an as to become subject o de Workers''Compcnmtion
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compe nation provisions of the Labor Code,you most
.J'Z forthwith comply with such provisions or this permit shall he deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
(-m I hereby affirm that there its construction lending agency for do performacxx of
a7 the work for which this Permit is issued(Sec.3097,Civ.C.)
W A Lendcrs Name
6. Lender a Address
V C) 1 ecairy that 1 have read this application and sue that plc above information is
W p correct.I agree to comply with all city and county ordinances and state laws mlating to
0(J building construction,and hereby authoris representatives of this city to enter upon plc
,rW ehme mentioned propery for inspection purposes.
F CL. (We)agree to rove,indemnify and keep harmless the City of Cupertino against
h liabilities,judgments,cooks and expenses which may in any way acc=against Said City
V Z a consequenccnfthe ramingoflas it.
^' APPL RSTAND ILL COMPLY WITH ALL NON-POINT Issued by: Date 2
CE ' LATION$
m C� Re-roofs
lure of pplicamU for Da
A DOUS MATERIALS D OSURE Type of Roof
Will the mart or future building Occupant tore or handle hamNous material
as defined by the Cupeninn Municipal Code,Chapter,9.13,and the Health and Safety
.We Section 8532(.)? All roofs shall be inspected prior to any roofing material being installed.
E]Yea 9aNo
Will the applicant or future buildingcecupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hacurdous air eumen insmi as defined by the Bay Arca Air Q,mloy Management all new materials for inspection.
vicR
❑Yet No
Ihirom" clog. u is re nu under Chapter 6.95 of the Califon
Dia Hcal SaryCW as2550 3 d 25531 undcrsund thuif the building
ds I cmrcmly h a urm�L t is r pomihllrty m notify the mcupant mf plc
r aiecm esu nfaCertiBeemofCCU r' SigriatureofApplicant Date
/1 _ aa 2pO`f
Date All roof coverings to be Class"B" or better
0 or au omi.eda
r
- CITY OF CUPERTINO
CC, TEMP POWER
UPE(�TINO PERMIT APPLICATION FORM tel'
APN # z 61
/ Date:
Building Address: (� A � q Sp1 c f
IO�' $ ' �}OI-INs' (TON \/�,i r ure +c .nm
Owner's Name: Phone#:
Contractor: Phone: License#:
Contact: VA
/ Phone: Cupertino Business License#:
�=z—> LIS �r�o✓�
Building Permit Info:
Elect ❑
Job Description:
Residential E Commercial ❑
Cost of Project:
Q
A tY is le Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC, Business License BUILDING