05060031 CITY OF CUPERTINO '� - �"�
BUILDING DIVISION PERNIIT SCO-NfRAC'TQR IORMATIgN
BUILDING ADDRESS: ROCKWOOD CONSTRUCTION CORE PERMTTNO.05060031
10614 RANDY IN
ME: PERMIT ISSUE DATE
SHAHROKH DEILAMI 14583 BIG BASIN WAY STE 3-A 09/23/2005
PHONE: SANITARY NO. CONTROL NO.
(408) 868-9026
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300 LICENSED CONTRACTOR'S DECLARATION lob Description
4 u i 1 hereby affirm that I am licensed under Pmvboans of Chapter 9(commencing
with Section Mar)of Division 7 ofd&Business r Professions Code.and my lkemeis
in full fora and effect. SFDWL-2 STORY (34081 LIVING)
jJz teem.Clan Lk.w GARAGE 439 '
Data Contractor
ARCHITECTS DECLARATION
I understand my plans shall M used as public records
Itsed Licensed Professional
OWN
ER-BUILDER DECLARATION
I hereby aRrm Nn 1 am uempt from Ne COnfeamars IJcenu law for the
o D following reason.(Section Na 1.5,Business and Professions Code:Any city or county
$ which requires a permit to conswet alar.Improve,demolish,or repair my auuctum
�Yy+ prior to its issuance.arm requires du applicant for such permit to file a signed statement
g that he is licensed punuentto the provisions ofthe Comuter'sU.nseLew(Chapter 9 Sq.Ft.Floor Area Valuation
$ (commencingwith Section 7000)ofDivision Jofthe Business and ProfatlonsCode)or $711832
that be is exempt therefrom and the bub fa Ila staged exemption.My violation of
Secthm 7031.5 by am applicant for a permit Objesu sea aPPlkant m a Civil Penalty of APN Number Occupancy Type
not mom Nan five hundred dolurs($500).
❑1.as owner of the property.a my employcn with wagon se their Ole compensation,
will do the work,and the =turn b a
notinndem
d or offered nan(Sao 7014,Business Required Inspections
and Profesaiou uO
Code:The Conmr's Liana Lan,ladean ant apply m an Owner of q P
propeny who bulldsorimproves Neeson,and who doess rch work himselfor through his
awn employees,provided that such improvements au nolnmrded aroRercd for tele.If.
however,the building or Improvement is Old within one year of compledon,the owner-
builder
wnerbuilder will have the burdan of proving that he did not build Or improve for purpose of
ule.y.
1,ru owner of the property.,B cauclurvalyand confession$with licensed Onuaemn construct La ch pmnot (Sec.70/4,Business and Pmfmoau ds or
The Conuanofa IJ-
whsa Saw dao not apply je ts owns Of property who undiu orram in t e Ceara,and
whocontractsLacta for projects with acontrOmNnl lkenudpursuantu theContractor's -
Lkcnu Lew.
❑I am exempt under ec ,B k PC to Is moon
Data
BR'S COMPENSATION DECLAKAI IO
I hereby&Blah under penally of perjury Oa of the fallowing dGINIION:
❑I have and will mainuin a Cenifiaceof Cansem to self-Insure for WarkeraCompen-
sadon,as provided for by Section 7700 of use Labor Code.for the performance of the
work for which this Permit is issued.
❑I have and will maintain Worker's Compensadon asurame.an required by Section
57W of the labor Code,for the perfomaae of the work for which this Permit is ivad.
My Workels Compensation Insurance carrier and Policy number are:
Carrier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleed lithe Permit Is for one hundred dollars(SIM)
or leu')
I certify Jut In the performance of the work for which Ni.peralt Is leveed.l Nall not
employ any person in my mannerO arisen'Com wtha
Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenifina of Exemption,you should
become subject to the Workers Compensation previsions of N.Labor Collo,you must .
Q'z forthwith comply with such provtsians or this pared shall he deemed revoked.
ZO CONSTRUCTION LENDING AGENCY
[-n Ihareby affirm that Neu in.cemtroc0a andingagency,far the p.K.Ona m.1'
a
~� the work for which Nb permit I.issued(Sec.3097,Civ.C.)
W n. Lender's Name
G7 z Lemicen Md.
t)Q I certify that 1 have read this application and since that Ne above Information in
ly!' correct.l agree to comply with all city and county odWnces and Stam laws relnins m
Q ICJ building convection,and hereby emborim representatives of this City m enar upon the
W whoa-mentioned Properly for inspection purpees.
(we)agree to save,indemnify and kap harmless the City of Cupcnino against
y7 liabilitiesjudgments,costs no expenses which may in my way aceru against Old City
(j7 In consequence of the gaining of this permit.
r� APPLICANT UNDER S Np iD WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGUL 9/ / V /I
Gn�Q� Re-roofs
Signa arc O! p HAZARDOUS MATERIALS DISCLOSURE Data Type of Roof
Will the applicant or in=building oceupmumre orhandle hazardous material
defined by the CupeNm Municipal Code.Chapter 9.11,and Jin Health and Safely
usection 15552.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes p+
Will the applicant or future building Occupant use equipment or dwices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air cenumin..as as Jafincd by Ne Bay Area Air Quality Management all new materials for inspection.
District?
Dyes Na
I haveread the buartlmu m rcrialsonpirements under Chapard.95 of tle Califor.
ni&HolN&SafayCodc,Sccdau25503,23533 and 75534.1 indenture Ihuifrha building
dean ant currently haw a a 4 Nat it b m mftelity u notify Jin occupant of Nc
reyuiremc 'or anceohCenificseof to .® ignature of Applicant Date
Ownerorsw orizoaagent Dace All roof coverings to be Class "B" or better C,