02030139— BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
22435 SANTA PAULA AV MAHMOUD & AZAR SHAHRAM 02030139
OWNER'S NAME: APPLICATION SUB DATE
Ah,MAHMOUD & AZAR SHAHRAM 03/25/2002
PHONE: SANITARY NO. CONTROL NO.
,
O m0 ZZ ARCHITF.CT/ENGINEER: BUILDING PERMIT INFO
mF BLDG ELECT PLUMB MECH
<6 r '71 I--I I= I- U
S
LICENSED CONTRACTOR'S DECLARATION w b I hereby ruffian that 1 am licensed under provisions of chapter 9 (commencing T�����T///www TTi]/!11///111T Job Description
:_Cum, wishSection7D00)ofDivision3ofNeBusinessandProfessionsCode.andmylicense SWIMMIL�.P,�p
s^� in full home and effect. Ae leV� ��®
w Q License Class Lic a
o O v. U Date Contractor
3 o a ARCHITECT'S DECLARATION UN 0 7 2002
I undersmnJ my plans shall be axed as public rcmrds
T
I E5'O C Licensed Ihofessional
'X OWNER-GUILDER DECLARATION BUILDING
I hereby off that 1 am exempt from the Contractor's License Low for the
F z < following mason. (section 71131.5. Business and Professions Code: Any city or county $25000
E i p which requires a permlt to construct. m
, aper, improve. demolish. or repair any Stmm
ctu
.pmommit%Jsddomc,rbw9 th ppl'amfor.euchpermiuofl 'gnW summers _
n3— he[khvemeni ing with
700dft of ticks BujitesL La (Chapterl p� _
g 1 it< yj [3,�. (,r +7 f 1 Valuation
(erns th4 CI ]afMl fD nlofth<Bu u dPruf6 SCode7 J � I .. ��g.(� ,�Cl,�•,?sJ jyl�J':'`
of Se hers exempt tnercf ons and the brut for the subjects
m 0 a<mpnt t Any violation
of Section TOJ LS by any applicant for apermit xubjans Ne applicant m v evil prnelty
of net mate than use hundred dollars (ssw). 10 - IPNit�ftl r. •at Occupancy Type
❑ 1, as owner of the progeny, or my employees with wages m their sure mmpctsmian,
will do the 'work. 'and the stmtlure is not intendcd'or offered for Sale (See 7044,
'Business and Profession code: The Contmcto; s License Law does not apply to as 107 - POOL/ B05iIIlltl GI Inspections
owner of progeny Who builds or improves thereon, and who does such work himself
or thrauggh his awn employers. provided that >.an improvements dor am intended or 3 01 - ROUGH PLUMBING
Rnarie. IL however, the building of bripmvermal is sold-within "one year of. ..._ .... _. _ .. _.... _. _ . -__ . ....- ...
'completion, the awneoldolder will have the burden or provinglhat he didnm build or 304 - ROUGH ELECTRICAL Ir,,*'
improve forpam"'°afrde., 502 - FINAL PLUMBING ENERGY
=aw«annp �y.amexw5iadyanGeJBwiroucensedcontractors io 503__ _FINAL-MECHANICAL ENERGY_.•.,:
Lionstmer the project (sec. 7044, Business and Pronasion, Carl The Comorcmr't 1
cense law does nor apply m an owner of property who builds or improves thereon. 5 0 6 - GAS TEST ,
:- _.vnJ who cmeatuch pears ca.with acomarctor(s) lcetud.punuant ta.the - 5T0----FINAL-PLANNING
mctoa mcam:
— -. ...----
-':❑�ly/am<xem t " R'. COMPEaNts� ,B@PCfonhis rcawn 511 - FINAL POOL" is-: '�'•:�,.;, -- "'-._.. _ _
- D ATPblDECLARATION � 516 - FINAL BUILDING
-f� 1 hembY allunder,.mIly afprijJaryone of me mllowing declarations:
❑ 1 have and volt maintain a certificate of Consent to Sea-inure for Workers
Compensation, as provided tis by Section 37MI of the Labor Code, for the
-
Performance of the work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, tat required by section
wt 3700 of the labor Code, for the performance of the work for which this permit is
issued. My Workers Compensmian Intimater carrier and Policy 1 Policy N.'.:
numherarc:
. 1 :.. . 5 s...., .
.CERTIFICATION OF HXEMPIONFROMWORKEltS f
1 ` _, - ,,. COMPENSATION INSURANCE'' _
i. .,..._ .._... _..
" (Thti set on need urn he completed if the peau t is for one hundred dolman
(SIIXq or less.
1 certify Ihoi in the xrr"rmaace of tnc work for which tti F<mmt is i ...ed, I
,hall net employ any Person in any manner so oto bccomc subject a the Workers s t
Compenmtion Laws of filiform.. Date -
..Applicant • . . _ .: _, .._._.. _.. __ _ .
NOTICETOd1. APPLICANT. Worker's
his Certificate or Labor Con. de. you
becortK mbjeci a the Workers Compcmethis provisions of the Leber revok you muss
z '� forthwith comply with such provisions or this permit shall be Deemed revoked.
Z H t- - _ _CO RUCTION LENDINGAGENCY'
CONST
F � •" i Ali., affirm that k.it is construction lending agency for the performance n'
'� Leshe work for which this permit is issued (Sa. 7fN], Civ. C.1
�•� Lend N ..r„.._
=.z lxndcrs Adac v- ... I l
V'0 1 certify that I have read this application and state that the above information is
lit' ,mn t. I agree to cote with all cit d count dlnances and state laws relating
F comply yam rail g
:Q•V the above-monmmcd propndhembyamhemer<pares. ex of shit citymrnar upon
Fythe abovememioncd property for inspection puryous.
l (Wd)ag' ,indemnify and keep harmlcsiihe City of Cupertino against
N liabilitlu.e)vsta and expenses which may in any wayaccrueagainst saidT). z City in cante u tl ND W' ILL COs. -T. A D((jtiND,WILLCOMPhYWITHA' Issuedby: D
g amrco ApphcanVConlmaor�Dene'; Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the ppll t m from building ocurpon come or handle haldradoxiis mammal Typeof Roof..--
ax
.. .. _
'defitardl by me C.scrim. shmerud Code Chapter 9,12.and the Health and Safety-
Code Sexrimn 2553,20,)?V
ElY` ”' " " _ - r v� 1l '1 . _ Allh. roo,fs shall be inspectedspn 'r to.any roofing, material being. installed.
tt In
will We alpha ant t Wilding ldingoccupantuseequip t or devices which If a roof Is installed without first obtaining an inspection; I agree to-remove
oil ezeiJousarconmmn is as aefned by M<Bey Aiea Al Qu lny Management
all new materials for inspection. Applicant understands and will comply with
ov Y. yi, Uro all non-pointsource regulations.
hi <'rcad the �haaardo s materials requirements under 61horpre, 6.95 of the
California Health & Safety Code. Sections 25505,-25533 and 25534, 1 understand that
ifthebtildgd sot [[[rrr 0/h atenet met t is my responsibility to notify the
occupant of the q sec sada Vic
list beausetymarm issuance of ificate of '
reap my I`I1VA,/I 2 Signature of Applicant Date
wteror.ptm :edagem CLVA apse All roof coverings to be Class "B" or better
'- _ ' OFFICE'