05040163 CITY OF CUPERTINO r`" '�'-'
BUILDING DIVISION PERMIT CONTReCTnRhINFORMATIO`v` .
BUILDING ADDRESS: PERMIT N00 5 0 4 016 3
620 MR11TMIS CT
/ OWNER'S NAME: PERMR LSSUE DATE
PARVIN SYAREH 2005
E: SANITARY NO. CONTROL NO.
ry
ARCHITECTMNGINEER: BUILDING PERMIT INFO
BO ELECT PLUMMECH
O
OM'z LICENSED CONTRACTOR'S DECLARATION lob Description
i� 1 Iwmby affirm Wt I am licernmi under provided;of Chapter 9(commencing
with Section 10(l Dwidon Sof the Business and Profeuiau Code.and my license u
I.full ImuctndeRett AD 944 ' (BEDRM/BATHRM/KITCHEN) &
LiceDan ClLt..« GARAGE-488 '
�e ARCHIIECI-S DECLARATION
y I wdenaand my piss shall W used as public records
O
iQM Licensed Professional
OWNER-exempt frDECLARATION /p��
1 hereby affirm that I am BUILD from the RATIO ars Liccnn law for the ((�{I��T'
D o fallowing mann.(Section 1031.5,Busmen and Pmfesriuu Cade:Any city or county
$ which mqubes a permit to coexuue alter.improve.donedum,m repair hay mumme
FZ12 prior to its Issuance,RIM MILPI a the epplieam forsuch Permit to rile a signed statement
Fss< Nat im is licenwd purnanua Ne pmvisiou of Ne Co.=Wes Umnn 6w(Chapwr9 Sq.Ft.Floor Area 1ia8 0 0 0
YFtt (commcmmngwith Scctlon?OW)ofDivisian3nfiMBasI..MPmfenions Code)or
fi that he I.exempt and exempt therefrom basis far Bre alleged exemption.Any AntRl6n of ll!A/
Section 1031.5 by arty applicant for a par th subjects the Applicant to a civil penally of APN Number - 'y 8ecu aney
ret mom Gun five hundred dclWl(S5W). 37526012 . 00 ZG 0 p Ty�
❑[,uownu of won pmprny,INmy emPloyw with wguu Heir vele eanpenntlon, m.— p/(s
will sur the work.had Nemucwmlsmr's Lt.doraw ed mosso apply oano owner
of Re 1 l"k b
ant Pm,who ns,bas Code:The Casae ase,License law soda not Apply lf rt awmr is U/)(,'J IttC{I7f/P�
own
property,who builds INimpmwa shesmgaM Who sure lueh Walk hlmselred Nmugh his
own emplaym,provided shssaueh improvemnts tie nminwMM maneed Tressle. .
builder,Ne building or improveracm
moving
hath within one year or completion,the owerr-
- builder will have the burdn in
of proving Nel W did not Wild or improve for purpose of
nleY
MI.u owner of 1W pmpenY•a elusively contracting with licensed conaumn w
haver Ute Pmjett(Sec.1016. 'nen And Profcaalaits Cade:)The ConOacurs Li.
«nn law dues not apply ton of property WON or improve Neuron,had.
who corormis for such projc N a wneamar(U lice d pmsueit to the Contractors
L'Ann law.
I am exempt under 3 B&P C for this`rearm
nm Date / J .
ORKERS COMPENSATION DECI.AkATION
1 hcmby amnn uMer penally of perjury om of the following declantioe:
I hero end will malmaln•Certificate of Consent N self-inure fo Woren's Compcn-
wian,u provided for by Section 3100 of the labor Code,for she pemannnce of Ne
wok for which this Permit is Issued
❑I hew am
will melanin Workers Compenntion Insurance,u required by Sued"
31110 of the Labor Code,far the
performance of th wok fm which Nu Permit is lured.
My Workeh Compenudon Insurance carrier and Policy number am:
Cartier. Polley No.:
CERTIFICATE OF EKEMPnO FROMWOPIKERS
COMPENSATION URANCE
MisscmionnumnotWcomplewdif permit is foronc hundred dullard({100)
ser less.)
1 Modify out in the Performance of the r f whle Nis permit is issued,I Mall Inst
employ any pctaun anymnmrn in y a tt.ftworle.,com
Laws of California.D
APplicam
NOTICE TO W ,a imp Ltd.Omificate of Excmptan,you should
become abject w she Worker's Compensation provisions of shd labor Code,you most
0z foMwith comply wish such Provisinu at Nis permit Nall W seemed ranked
z CONSTRUCTION LENDING AGENCY
EIWmbyefnrm NU Nem is a construction lending agency for she Performance of
- > the work for which Ihls permit Is issued(Sur.3(]91,Civ.C.)
14Q Lender.Nurse
cj�=z LanNrs Address
U Q 1 enlfy Net I have and this application and sow that use above information u
{>r comes.I agree w comply wish all city and county ordinances and sum Ism Rioting w
O building convection,and hembyaushoomw mmnivcsaf Niscity murder upon Ore
til above-mentioned Inaptly for 1. he pas a
Py (We)agree to haw,indemnify n pan nnleu Ne City of Cupertino against
m Iiabititie.lMgmeme.comaded ich ay in nY wI, ocrue against said City
U 7 In eomsegmmr:of the Panting of N' 16
r7 APPLICANT UNDERSTANDS D ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG L TIONS,
Re-roofs
SigaRureaf Appl on ave
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicam or forum Wilding occupant Raw or handle hactrdous material
M dented by the Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
Code. El es 25532(a)? All roofs shall he inspected prior to any roofing material being installed.
El Yes ❑No
Will Ne applicant or future Wilding occupant ton equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
It Imaumv sir come"M 13 u Med by f Bay Amo Air Quality Management all new materials for inspection.
District?
❑Yee u
I have mol the hued materials requirements under Chamer 695 ofthe Cantor.
w Iti sk SafciyCode, d 25505,35533 aru125534.1 undersuM she ifne Wilding
does not currently have NR it is my responsibility w notify Ne occupnt of the
requirements which I I poor to issuance or a certifies r cul" IgnatUre of Applicant Date
weer r. adeee.gent Date All roof coverings to be Class"B"or better