06030092 CITY OF CUPERTINO
BUILDING DIVISION PERMIT Ci)NTRACTO,RINFORMr1.TION ;_
BUILDING ADDRESS: REZA SADJADI PERMIT N0.06030092
1272 POPPY WY
NER'S NAME: PERMIT ISSUE DATE
REZA SADJADI 04/10/2006
PHONE: SANITARY NO. CONTROL NO.
ARCHITECfIENGINEFA:
BUILDING PERMIT INFO
BLDG ELECT PLUMB METH
0 0 0 0
lop LICENSED CONTRACTOR'S DECLARATION - Ib Description
U C 1 Wmby affirm am that 1 li¢vOIP
cd under provisions of Chapter 9(commencing
tt aith Secdon7000)of Diision 3 of the Badness and Profcuiuru Code,and my license is
? y infull force and err L KITCHEN REMODELTHROOM REMODEL
s n Z License Clea Lic.N
a Dam Commeer MINOR STRUCTURAL, M
saJ` ARCHITECTS DECLARATION
m< 1 understand my plants shall he used as public records
)C.
sod Licensed Professional
5 OWNER-BUILDER DECLARATION II co N1oo(a
f I hereby.]fico I am exempt from Ne Contractor's Law for me UU
00 (allowing mason.(Section IID 1.5,Bonn.and Pmfmsium Cale:Any city or county
m which requires a permit ro cnowmct duan improve.demobh,or repair any suueum
prior to as Rauamc.also acquires the applicant for Such Permit to rile a signed Statement
< taut he k]teemed pumoanmt ro the providon ptthe Cwuacm/s IJarnse taw(Cbapm 9 Sq. Ft. Floor A Valua' slab 0 0 0
x (commencing with Scedun 7000)o(Division 3 or the Business and Professions Codc)or
i
that W u comp,therefrom and um basis for the alleged asmnpdo.Any violation of
Smion 7031.5 by any applicant for a permit objects the applicanuo•civil penalty of APN Number Occupancy Type
dot mom man fiat hundred dollars($500), 36619043 . 0 0 P y YP
❑I.u owner of the property.or my moployen with wages as their ask eompemauo,
will do thework,and the structure is nmimmndolmoRened fmoa (See ID .Business
and Professions Code:The Comeacuh License Law docs ant apply m an owner of Required Inspections
property who builds m impmvn thereon,and who dos such wort himself or through his
Own employees.provided that such improvements ane not inundrd aro@red torsade If.
however,the building or improvement usold within one year of mmpiwon.the owner,
builder will have Um burden of proving Nam he did not build or improve fm purpose of
sale.).
❑1,as owner of the property.am nelusively Command,with licensed eonuactors m
construct the project(Sri.7054,Business and Profnsions Cade:)The Canuazmri U.
cense Law don cot apply man myna of property wind Wilds or improves themon,and
who tomenta for such pmjecm with aconmetor(s)licensed pursuant to the Conorreves
License law.
❑Ion nampt undo See B k P C for this mason
n Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirms under penalty of perjury one of dme following deeknm outer
❑1 toward will maintain aCertifmnk ofCmmsom m self-insure fmworkcescmnpen-
sation,u provided for by Section 3'100 of the Labor Code.for the Koinumann of the
work for which this Permit is issued.
❑1 have and will maintain Workers Compnution Insurance,u required by Section
3700 of the Labor Code,fm thc performance of the work for which this permit is tuned. '
My WmkeYs Compenudon Insurance canner and Policy number are:
Carrier; Policy No.:
CERTIFICATE OF EKEMPrION FROM WORKERS'
COMPENSATION INSURANCE
(Thts section most not he completed if de peri,is faronc hundred dollars($100)
car lead)
1 certify that in one perfomanec of dm work for which this permit is issued.1 shell on,
employ anyperson in any manner.u to bnome subject to the Wortrn'Compensation
laws or California.Dam
Applicant
NOTICE TO APPLICANT:IL arm,mating this Cenifinm Of Excra,amr.yo ahold
bmome subject to the Workers Compensation provisions of the Ichor Code,you most
.J z foMwith comply with such provision ser mu permit shall be deemed rooked.
z O CONSTRUCTION LENDING AGENCY
f-' 1 hereby arum mat mem In.ememuctim lending agency for the fa rfamance of
C' the work for which this permit Is issued(Sec.W.Civ.C.)
lender's Nme
=z IeMcrs Address
U Q 1 certify that I have mad this appli'mo.add sum that the above infamswo is
ly Pcomm 1 agree m comply with all city and county ordinances and sure laws reaung to
C)U building Conawction,and hereby authorim mpmecmftncs of this city m enter upon the
dhow-mcnudgm property farterpenes ptopowhich ma
F a (We)agree to ave,indemnity and tecp ha Mess lire City of Cupertino against
rn
liabilities,judgments.the growing expenses which may in anyway accrue agalmasaid City
U z A PLICAence of the UNDERSTANDS
of this D WILL
t—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURCE REGULATIONS.
Signature or ApplicanVCaRe-roofs
Dak
HAZARDOUS
MATERIALS DISCLOSURE Type of Roof
Will the applicant or future
furore building eChapter
or handle hvallous matmaterialri
as defused o the Cupertino Municipal Cade.,Chapmr 9.I1.and dm Health and Safety
-code.5ccuon 155324)?
❑Yn C]No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant o,future building asupanm uta equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haramous air contaminants as defined by the Bay Amo Air Quality Management all new materials for inspection.
DissriW
❑Yes ❑Nu
I haveread the Wan =mvc alsmquimmemsunderChepmr6.95oftheCdiror-
nis Hcalth&Safcty Code.Sced.n5B5.25533anu125534.Iundersundthmifthe building
does on,Currently have a conn.ma,it k my responsibility to usury dm oavpen,Or the
mgeirementa which coria be met on,to issaancc of a Cmtifinm or Occupancy. Signature of Applicant Date
Owner or anthari,.adagent D,m All roof coverings to be Class"B"or better