05020163 CITY OF CUPERTINO +'0dit=* �'�fi h 'r` "' "`�'' �• a
BUILDING DIVISION PERMIT CON '" QVINFORMATI0N !g,
Bull
LONG ADDRESS: PERMIT N'05020163
OW NER'S NAME: PERMIT ISSUE DATE
JOHN GHASH
E: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
X0i LICENSED CONTRACTOR'S DECLARATION Job Description
1 Mreby arfrm Nor 1 am licensed under provisions of Chapter 9(rnmmencing p
with Section 7")of0ivision SofNe Businu,and Profcssimu Code.atl my license is
, imm�mro andercen. ADD 2155 ' (1658 ' LIVING)
License Class Lic.M
Dow Contractor GARAGE 497 ' & REMODEL 3635 '
ARCHITECT'S DECLARATION
u1 mWcrwnd my plans shall k used u public records
w
GG Licensed Professional
3 OWNER-BUILDER DECLARATION
1 krchy,affirm Nat I am exempt from Ne Contractor's License Law for the
00 following reason.(Section 7031 S.Business and Professions Calc:My city or county
$ which requires s pewit to construct,alter,mourn, kraolig.ar repair any nooem.
_Z< poor to its iuuawealuamxpirts Neapplinat forsuch Pcrenitutfile.ailneduaternert
££m¢
Out k is licensed pursuant to Ne provisions of Ne Connectors License law(Chapter 9 Sq.Ft. Floor Area Va"t*000
YFm (commencing with Section 7")o(Division 3 of The B usineu and Profusions Codd)or
-�
i Nat as is exempt therefrom and the buts fm the alleged exemption.My violation of
Section 7031.5 by arty applicant for a pennh subjects Ne applicant to a civil penalty of. APN Number Occupancy T
out mere than En bewred donars($500k 35708016 . 00
p y yl�
❑I,uownerofthepmpeny,ormyemploymwiNwagesu Nebhalecampenution,
will do Ne work,and Ne structure is not intended proffered Wag.(Sec.7004,Business
and Professions Code:The Committees License Law docs set apply to an owner of Required Inspections
propenywho buildsorimpounds toodom,and who doessuch work himselfarNrough his
ownever,Am Wiprovided p such improsomenuuenot intendedmoReso,foe nle.IL
however,Mme Wilding m impmvome in u halt within one lav of completion,Ne ownor-
builtler .will have Ile burden of proving that k tlitl not Wild or improve for Purpose of
sale.).
❑1,as owner of on,property,am exclusively conuacting with licensed contractors to
construct Ne ysonot (Sec.toad,weer of and property
who
Code:) pr Contractor's rad
cense low texas not apply to an owner of property wce Wilds or improve Norton,and it
who contracts for snub protease with a contractor(s)licensed pursuant to Ne Conuacrafs
License
ense LLaw. /
❑loto exempla/deer$�ec�� � B&PCfar Nls reason �
Owner \ [_/�j Dau
WORKERS COMPENSATION DECLARATION o/
I hereby affiun under Penalty of perjury one of the following dxhntiou:
137Wof
haus and will maintain a Certificate of Consent to self-insure for Worker's Compere- /�
n,u provided for by Section 37M of Ne UWr Code.for Ne performance of Nc (`�
for which this permit is issued.
hale add will maintain Waken Compensation Insurance,u required by Section
Ne La Wr Code,for Ne peKormantt of Ne work for which Nu permit is issued.
Worker's Compensation Insurance Cartier and Policy number tie:
Cartier: Policy No.: _
CERTIRCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu action need nm k completed if On permit isforoac hundred dollars($100)
or less.)
1 certify Nat in the purformarcc of Ne work for which this Permit u issued.I shall net
employ any person in my saw. R..2 ay¢Workeri COmpcuauon
Laws of California.Dau�1,
Applicant
NOTICE TO APPLICANT:If,alum maks g this Certificate O Excmprio d you should
.,0become subject y it Worker's CompensationtOtiprovision of rho V Wr Code,you must
forthwith comply with such prmisions or this pcnnis shall be dccmrA revoked. ,
Z CONSTRUCTION LENDING AGENCY
[—� l kreby arlism NU there is a mmuctinn lending agency,for Ne perfornantt of
C(. the work for which this Permit Is issued(Sec.3047,Co.C.)
(e]Q Lender's Name
7 z Undees Address -
U Q I certify that 1 Mvc mud Nis application and sou Nat Mu eWse infowatiun u
17. correct.1 agru to comply with all city and county ordinances and sure laws relating to
Of, Wilding construction,and hereby aurhmiou nprosenutisss Of this City to enter upon Ne
show-memorned property for inspection purposes.
D. (We)agree to cave,indemnify and keep harmless Ne City of Cupertino ageing
Tn in
expenses perm which may in anywyeccmc againstsaiOCity .�.
V z in consequence a Ne Ranging Of exNis es whi
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT Issued by: Date
SOURCE REGU ONS
te Re-roofs
Signgure of APPlicuMCon for Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or future Wilding occupant gam or handle hnudou material
As defined by the Cupenino Municipal Code,Chapter 9.13.sed Ne Health sed Safety
our,Section 35532(a)7 Yea KN. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding aceupent use equipment or deviw which If a roof is installed without first obtaining an inspection,I agree to remove
it havardnua air eonuminanu as unhand by Ile Bay Area Air Ouslity Management all new materials for inspection.
grict,
�n❑re.
I have mad the hecasdousmaterials usio cmenu under Chanter G95 of Ne Califor
niaH lNkSafctyCale.Sceuo UM5.75533wd735J4.lwdcrsusmN if No Wilding
does nor curenly bast a unam,that it u my nesperc hility to wary Meas upon of Ne
require l9kswn�apmustx�p,io(to; u wearacertrna preop Signature of Applicant Date
C` ICt cur® r
Owner or amhorind ag rel Date All roof coverings to be Class "B"or better
C