03040094 CITY OF CUPERTINO ",,OR
BUILDING DIVISION PERMIT k_XONTRACT,QRaINFORMATION'�
SS.���. ;x O
EUI6DSN ff"ta,WfA. LUCIA RD AHMED DWIDAR PERMIT NO.03040094
AMW"lVlD71 EDWIDARl7
PenmrrLSSI1EDAlE /2003
E: SANITARY NlOJ.4 CONTROL NO.
ARCHITECnENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
jGo LICENSED CONTRACTOR'S DECLARATION I Job Description
IF 1 hereby afOrm Ihes I am licensed under provisions of Chapter 9(mmmcncin{ p -
s� with Section 70rl))uf Division Sof the Business and Professions Com.and my license is
n oPill
eneClass derzect. REPLACE
iJ Licence Clans Conti
7 F Dem Cumrsdor
gg ARCHITECTS DECLARATION
f 2 I underutanJ my plans ahail be uuJ u public records t
Si
cG Licensed Professional
7 3 OWNER-BUILDER DECLARATION
d OOI hereby maso .(fere that 11. exempt from be CanCos License law for the I
p O following reunn.(Section 703 coon. Business and Professionsde Coot:Any city or county _
5$ which myuims a permit re enniwm,slier,nt rrow,dconsitt or recede any atrucmre
prior-iy
that he
incensed galso
uantto res the provisions of
ear such Connermitmfento Law(ata¢mem
[�< m mountingsedpuntion7 thepmvivision3ortheBuucestandcnselawlChapter 9uts)or Sq.Ft. Floor Area �glg�fion
p that he ,examwiththerefrom and the
Division r the
the alleged
euantl Profeson.Any
late.or
��$ that he ie exempt therefrom and Ne buts for Ne alleged exemption.Any vinlatlon of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of 3 ABJ4 DIO)Mr O O Occupancy Type
not marc Nan five hundred dollen(5500).
I,as owner of the property,or my employees with wages as their sole coopenatin,
will do one work and the ewctme is not imended offered for sale(See.IDN,Business 101 - FOUND
and Proressions Code:The mm
ConcYs Licevdao m
e law s apply m an owner of d Inspections
property who builds Or improves dumin.and who doessuch work himselfor through his 102 — PIERS
own employees,provided that each improvements am not intended ororfemd for als.If. 103 — UFER
however.the building or improvement s sold within one year of completion.Ne owner-
wilder will haw the bums.of proving Oat he did not wild or improve for purpose of 104 — REBAR
am,)' 105 — ANCHOR BOLTS
❑1.as the p of Ice progeny,am exclusively contracting with:)TheeComm Comment's
m
centuva does no,
apply to
aowner of and Profusionsds or
The Convenor:Li- 106 — SEWER & WATER
emusLaw tlocsnoupplmkcm with
aofpropenywho censed arrant in Ban themContrn.actor's
202 — UNDERFLOOR PLUMBING
who conu¢u for such projeeu with a conuutoKH licensed pursuant m tbe Convacrs
e^a Law. 203 — UNDERFLOOR MECHANICAL
tun exempt uncle sec. Bk PCfor this recon 204 - - UNDERFLOOR FRAME
r w. KM A NDECLAR "d,4111103 205 — UNDERFLOOR INSULATION
archyerrrmenderPenaltyofperjuryoneofinernuowingdecl.rations: 301 — ROUGH PLUMBING
❑I have and will maintain a Cenifeam of Conant to selbinsum for Worker's Cooper. 302 — TUB & OR SHOWER
radon,as pmvidcd for by Section 3700 of the labor Code,for the performance of the 303 — ROUGH MECHANICAL
work for which Nis pesmh is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section 304 — ROUGH ELECTRICAL
3700 of the LawrCook,for the performance of the work for whim this perms is issued. 305 — FRAME
My WmkeYa Consternation luunnce carrier and Polity number tae: 306 — HOLDOWNS
Cartier. CERTIFICATE OFEXEMPTION MOM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 — SHEETROCK
CThh accarm need roc be mmrlcmd if the permit is for..a hundred dollars($100) 309 — EXTERIOR LATH
nrlual
I coldly Nut in the performance of the work for which this permit is issued.I shall nut 310 — INTERIOR LATH
employ any person in any manner an as to become subject to the Worker'Compensation 311 — SCRATCH COAT
Lew.or California.Data
Applicant 313 — ROOF NAIL
NOTICE TO APPLICANT.If.after making this Ccnifcata of Exemption,you should 501 — FINAL ELECTRICAL ENERGY
become subject to he Worker:Compmuslion provisions of the Lacer code,you mull
7Zforhwithcomplywithsuchprovisinuorchisremthshallbeaccruedmvokes. 502 — FINAL PLUMBING ENERGY
zo CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
I hereby affirm that them its construction lending agency for the performance of 504 — FINAL BUILDING ENERGY
q
X F>-t the work for which this permit I.issued(Sce.3(197,Civ.C.)
4 Lenders Name 505 — FINAL ELECTRICAL
Lenders Add.
506 — GAS TEST
;,)p 1 certify that I have read this application and sum Nal the shove information is 507 — FINAL PLUMBING
w+
Correct.I&&Me to comply with a 11 city and county ordinances and sem laws relating to
building eumwcuon,and hereby amhorim repesenutivu of this city to enter upon the
shove-mentioned property for laureation purposes. rN — FIN L MEC ICAL
? y (We)all.I..w,indemnify and keep harmlessthe city orcupenim,against cn Ilabilities,judgoonts,coats and expenses which may in my way accrue against aid City
,Z in consequence of the granting or this Permit.
�OU
NGAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-P01 Issued by: C WORKSDa
SOURCULATION .
<< Re-roofs
ign w A u rector Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle haamuus material
as de(Innd by the Caperton Municipal Cudc,Chapter 9.12,and the Health and Safety
Com.sectio.25532(a)?
❑Yat IAll roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit huardou.air contaminants as defied by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes �Nu
Illave reed the waaNtms materials requirements under ChaPmri.95 of the Califoo-
iia H..IN,SafetyCodc,Somans 8505,35533 and 25534.1 undcmmM Not i0w wilding
dura nal m nay hew a tanam,that h is my responsihility m notify Ice occupant of Ne
iequimmen whit ualbem pammissumceofa Cenricamof Oecupanty. Signature Of Applicant Date
ow nri,e,dagent ( am All roof coverings to be Class"B"or better