05040136 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRAGTORI,NFORMATION
BUILDING ADDRESS: PERMIT NO,
MASSOUD VAMEGHI 05040136
ril 1A MAP CT
OWNER'S NAME: PERMIT ISSUE DATE
E:
SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
_cep LICENSEDCONTRACrOR'SDECLARATION Job Description
C I hereby affirm Net l am lianwd under provisions of Chapter 9(commencing
b with Section TWlBaf Division 3 of de Business and Professions Code.and my license is
s in roll force and effect.
e LiccnwClas Lk.N ADD PORCH/CHANGE ENTRANCE (lJIL
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�Fp Ga. Cunnaztor ®®paC®1
W ARCHITECTS DECLARATION
is z 7 I uMenund my plans shall M used u public meards
JatU
`0.�; Licensed Profcssioral
—03 OWNER-BUILDER DECLARATION 19' 2005
u<' 1 hereby affirm Not I am exempt farm the Contraztor's Lumnw Law for the
s 0 o following mason.(Section 703 1.5,Business and Professions Cade:Any city or County
K_a which myuiry a permit w construct,alter.improve,demolish,or repair any structure
prior m its issuance.also requires Ne applicant for such permit in file a signed statement
-s< Nat he is licensed pursuant to Me provisions of the Contractor's Liccnw Law(Chapter 9 Sq.Ft.Floor Area U I LMI'm
xF0 (commencing with Section 7")of Division 3 of Me Business and Profession Code)or
a that he is exempt Mcmfmm and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of 3 6Vk5*111tiM 0 Occupancy Type
not mom Nan five handled della,,($500).
❑I,a owncr of the pmpcny,or my employces with w gw u their wie compensation,
will do the work,and the structure is not intended proffered forsafe(See.10a 1.Business
and Pmssi
faons COMM:The Contractors License Taw does not apply m an owner or Required Inspections
property who builds or improves Maroon,and who dms such work himself or through his
own employees,provided Nat such improvements are not intended oraRered forsale.If.
however Ne building or improvement is sold within one year of completion.Ne owner.
bull&'will have Ne burden of proving that W did not Wild or improve for purpose of
talc.).
❑1,as owner of the property.am exclusively contracting with licensed carnations to
construct Ne project(Sec.?DNd,Business and Prefesaiem CWc:)The Contractor's Li.
cense law does not apply to an owner of property who Wilds or impowas thereon,and
who contracts for such projects with ae ntraztor(s)lice dpu ationn oche Connacme,
License law.
❑t oar es", a&,Sea .B k P-q fylr Nis rtsson
IC33111
er f1Pa"N Date"5j
R :R'S OMPENS O D LARATION
I hereby affirm under pemlty of per3ury are of the fallowing declarations:
have and will maintain a Cenificare of Consent w self-insum for Worker's Compcn.
n,a provided for by Section 3700 of the Inbar Code.for Ne performance of the
k for which this permit is issued.
have and will maintain Worker's Compensation Insurance.as required by Section
0 of the labor Code,for Ne performance of the work for which this permit is issued.
Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis.,d.need nor W completed lithe permir is far one hundred dollars(SIM)
or less.)
1 unify that in the perfatroma of the work for which this permit a issued.I shall not
court.;any pcnan in any mann .was m become ub'ecuothe Worn Compensation
Laws of Calif. Dam
Applicant 4
NOTICE AP LICA . ,of mak, tis Ccmfica11 c puon,you should
40(
become subject to Ne Worker's Compensation provisions 6 c Labor Code,you must
.,O forthwith comply with such provisions or this permit shall the deemed revoked.
Z' CONSTRUCTION LENDING AGENCY
Ihereby affirm that there is a construction[ending agency for the performance of
pvi the work for whiclyt))i iiiy ec.I(19] Cts,
CQ Lender's Namc / LA",•` 141
Z Lender's Address
U Q 1 certify,that l have lead this application and sow Nat Ne above oformauon is
f' cereal.l agree to comply with all city and county ordinances and sow laws relating to
0 building construction,and hereby authonn representatives of th4 city m enter upon de
r W aleve-mentioned property,for impaction puryasts.
(We)agree to save,indemnify and kap harmless IM City or Cupertino against
F y
liabilities judgments.costs and as,.which may in any way acme against said City
U incmtsegance of the Granting of this permit.
^ APPLICA UNDERSTAN A D WILL COMPLY LTH ALL NON-POINT Issued by: Date
SOUR GULATIONS.
/ Re-roofs
.�tmturc of ApphcimVCo mMMr Data
HAZARDOUS MATER DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant store or handle haardoa material
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
CoJc,Section 3553](,)?
YenAN., All roofs shall be inspected prior to any roofing material being installed.
lip Will Ne applicant or future buildin acca ant use equipment or Jeview which If a roof is installed without first obtaining an inspection,I agree to remove
pp g p aAirQn
emh District? as air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
Disuia?
Cl Ycs �Nu
I have real Ne haaardnus mawrialswquimments unJer Chapter 6.95 of the Glifor-
niaHcalitt'safctycodc,Socuau2SN)) 255J3and ss53a.Iwstar;rvM dncifthe Wilding
don not currently haae a was ,thou u mY sespm,i ilii{�,n�u fy the aeup im of Me
myuirrAi 6whmhmuuW et r wtseuane, aCc toMorOccapanay. Signature of Applicant Date
7 /
weer err aathori>ad ascot Dow All roof coverings to be Class"B" or better