06030046 CITY OF CUPERTINO q, '�• r�•
BUILDING DIVISION PERMIT raLO;lVR.diCTOR.7KRt1T
BUILDING ADDRESS: S SAKI 1ER1"ITNO.06030046
18661 MEDICUS CT
' R'S NAME:OHAPERMIT ISSUE GATE
MMMAD S SAMI 06/14/2006
PHONE: SANITARY NO. CONTROL NO.
ARCNIIECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O O
�00 LICENSED CONTRACTOR'S DECLARATION Job Description
de 1 hereby affirm that 1 am licensed under provision of CNpler 9 mommcncing
^
with Section ndefafDlvfwen3aftheBusiness and ProfessionsCodo,andmylicense ta SFDWL-3 , 329/BASEMENT 1, 040/GARAGE 457
In full fame end efface
CNi
LicenseClass
Catnctor FIRE SPRINKLERS ARE REQUIRED-PER FIRE DEPT.
ARCHITECTS DECLARATION UNIQUE CONST BL #26104-SANITARY SUNNYVALE JURIS
1 understand my plass shell W used as public records
0 Licensed Professional
OWNER-BUILDER DECLARATION
g I hereby aRrm that I am exempt form me Caauamofs Una.Law for the
COO following lesson(Semon 703 1.5,Business and Professions Cade:My city Or county
9 f which requires a permit to construct,all hnprove.demolish,or repair my Met=
–zY prior m nce
its issua .also requires the applicant for Such permit to Omml
le a signed alam
F O that he is licensed pursuant In the proviNonSOfthe ConuxtorsLicense law(Chapter 9 Sq.Ft.Floor Area Valuation
s; (commencing with Section 7000)of DiAskm 3 of the Busies and Professiona Code)or $962370
that be Is olation of
Section 7031.5 by airy ap Ikea four a permit>usjeeu basis for the alleged
applicant exema a civiliPenalty of
Typeset more Wan five handled dollen(5500). APN Number Occupancy Type
❑I,u awns of tan propmy,Unmy wploym with wages athetrank eompewton,
will do drewodc and the swctue,is not amended oraRertd forale(Sa.7044,Businesses Required Inspections
and Profesimss de CaThe Crmcto License Law dam set apply m an owner of q P
property who builds Unimproves thmcon.and whorl smcbworkhim fserthmegh his
awn employee,provided that weh improvements art not intended Unaltered for sales If.
however.the building or imporvemant Is mid withinem year of eempledon,the owner.
bulkier will have Uu burden of proving Nat he did not Wild or Improve for purpose of
ata,).
❑1,as owner of the Properly am ealusively conusctinL with licensed contractors no
emsuoct the project(Sec.7044,Businea and Professions Code)The Corlamrors Ll-
consul
cense law does not apply m an owner of property who Wilds ar improves Uwmon,and
who comacu for such pueecn with a contractor(s)licensed pwaanr to me Contractors
License law.
❑I am naempt under See ■d P C for this mar
JcS coar�,-lY
0 KER'S COMPENNS–_gATTION
1 hereby afftm under penalty of perjury arc of the following dmlarWonw
❑1 ham and will maintain a Certif hoof Canaent In Self-inaumfarWarkeYsCompcn-
sadon,a provided for by Section 3700 of die Labor Code,far me performame of the
work for which this permit is Issued.
❑1 have and will maintain Workses Compensation Insurance,as required by Section
3700 of the Labor Cade,for the pandumance of the wart for which due Permit is issmd.
My Worker's Compmadr Irssuresntt carrier and Polity number are:
Grim Policy No_
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSAT70N INSURANCE
(This=line need set be completed Lima permit is farm¢hundtddallan(5100)
reins) '
I cenify dant In the performance of the work far which this permit Is lased.l shall set
employanypersoninmymmmerseads mbemmcabje�m Works'Compema
Laws of Calirooda.Date
UTICST
At /
NITCE TO APPLICANT:Work.IL Nor making this Coni of Exemption.Cad you ahaesa
haeme, ItlUct comply
it Worh Floeel rian.or minermiitiha of thelabor Cade,yen mus
�O foMwith comply wise ash porvidona or mu permit shall W domed mated.
z tiCONSTRUCTION LENDING AGENCY
[.r I hereby affsm and dem is sconstnscUnn lending agency fm Use pnfommce of
ai '7 me wart for which this permit Is issued(Sec.3097.Civ.C.)
W� Lender's Name
z Lendeei Add.
U C 1 certify that 1 have and this application and suss that the Seem lot omati-u
w F correct.1 agate W comply with all city and county omfraness and mm laws miadng to
C U Wilding convection.and hereby intention represenutims ofthis city to Saar upon LOU
W aMvcmmmialmd Manly for inspection purposes
(We)agree In ave,indemnify and Yost,hussies,to City of Cupenirlo against
vw V) Imbilidet,Jdgments.cess and expenses which may In my way carve against cud onlyin t
of the
of this
U
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REGU TIONS /
Re-roofs
Signwureof Applicem/Conuseur Data Type of Roof
HAZARDOUS MATERIALS DISCLOSURE 'JP
Will the applies¢or future Wilding acupentsiore or handle harardaos material
as dcfimd by de,Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Sedom25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
If a roof is installed without first obtaining an inspection,I agree to remove
Wit the applicant or forum Wading rccupant ata equipment Ordcviw which
Until haramoe air conuminanu as darned by man Bay Am Air Quality Management all new materials for inspection.
Db4ict7 /1
❑Yea ❑Nu
1 have mad mehaardausmaurlals mquimmenuunderCTapur 6.95 of due Califor-
nia Hmdlh&SafclyCade,Sections 25505.25533 vu125534.1 underworld that lime Wilding
does not nmemly ham a tenant,that It is my responsibility to noUl' the aceupant of the
mqulm nu wh' maw W met ori m I uses of a Ccnifmau o Gccopasey.
9k�^� y .4 Z ^�y: Signature of Applicant g Date
A ir,�-+1 �— All roof coverings to be Class "B"or better
Owner or Authorized agent � 6w Dou