06020111 CITY OF CUPERTINO za . n!wa�, •�
BUILDING DIVISION PERMIT .�CONTRAC�TORIINFR NATION,`R
BUILDINGADDRESS: GARY STREAM CONST. INC. PERMITNO.06020111
OWNER'S NAME: PERM3T ISSUE DATE
JOHN GHASHGHAI 999 CHAPMAN ST Q-A / .81200C
�E: SANITARY NO. CONTROL NO.
(408) 247-2835
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
.C, LICENSED CONTRACTOR'S DECLARATION Job DOSCrIpI100 —
u❑ I hereby arm Nal 1 am licmuced under provisions of Chapbr,9(commencing
W with Section 7")of Division 3 oftW Rustication!ProfessionsCoda.and my license is
-cum, my z Licn Comrazbr ?✓S
REVISION--TURSS CAL.
e , DoreLic.
NO NEW PERMIT ISSUED/ORIG. #05020163
,J ARCHITECT'SDECLARAn NN
I understand my plans shall be used as public records
JaU /I
k nt0 t, Licensed Professional `
3 OWNER-BUILDER DECLARATION
`<F I hereby affirm shit I me exempt from the Contractors License law for the 0_ f.a\
00 following mason.(Section 7031.5.Business and Professions Cole:Any city or county V F
K m which mquita a permit to construct,altar.improve,demolish,or repair any structure
Lit prior in its issuance,also requires the applicant for such permit to File a signed statement
a that he is licensed pursumttothe provisions ofthe Contsacmr'sLimme,LawChapter 9 Sq. Ft. Floor Area valuatiOt*214
YFG (commencing with Section 7")of Division 3 of the Business and Professions Clue)or
y
that he is exempt therefrom and the beau for the alleged exemption.Any violation of
Section 7071.5 by arty applicant for a Permit ubjects the applicants to a civil penalty of APN Number Occupancy Type
not more than low hundred dollars(150B, P Y YP
p l.mo uoftMpmpcny,mmyemploycuwiNwa muvirwlemmpemuon, 35708016 . 00
will do the work,end Ne structure u.otinbndcd oronemd retail.(Sec.7014,Business
and Professions Code:The Contractors Li«nw Law does net apply b an owner of Required Inspections
properly who buildsor improves thereon,and who doeaauchwork himself or through his
own employees,provided that such improvements arc not intended mortared formic.IL
however,the building or improvement is mid within one year of complexion,the owner.
builder will have Be,burden of proving that he did not Wild or improve for purpose of
.talc.).
❑h as owner of da Prnpart,am uclosimly contracting with licensed c mmacmrs to
consumes the project(Sec.7014,Business and Professions Code)The Contracts's U.
cave law dors not apply to an owner of propcny.who Wilds or improsel thencon,and
who continues for such pmjecu with a contracbr(s)licensed pursuant to the Contractors
License Law.
❑I am exempt under Sec. B h P C for this mason
Owner Data
WORKERS COMPENSATION DECLARATION
1 hereby aRtm under pcvlsY of perjury arc of the following daclansions: ,
❑I haw and will maintain a Cenifcate of Consent to self-imure for WorkeriCompen-
satioq as provided for by Section 37M of the Letter Code,for the performance of the
ark for which this permit is issued.
C:]1 have and will maintain Worker's Compensation Tmurana,as required by Saturn
37M of the labor Cade,for the perfomance of the work for which this permit is issued.
My Wo s m motion Tnsmance trio and policy number am:
Casricc Policy No.: _
CERTIFICATE OF XEMP ION FROM WORKERS'
COMPENSATION INSURANCE
mets section need not W completed if the permit is fortune hundred dollars($IM)
or Iasi.)
I century tha in the performance of ted work for which this permit is imucd,l shall not
employ.ny perm.in any manner w as b became wbjaet m N.Workers'Compensation
Laws of Califomia.Be.
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcate of Exemption.you should
become subject to the Worker's Compensation previsions of she Tabor Code,you most
.Jz foMwith comply with such provision or this man shall W deemed rtwfkad.
Z71 CONSTRUCTION LENDING AGENCY
[-+ I hereby affirm that than,is a construction lending agency for Ne performance of
CG the work for which this permit is issued(Sec.3097,Civ.C.)
GLanders Name
]z Lender's Address
U O 1 minty than T have mad this application and sure that Ne above information is
IL f" correct.I agree to comply with all city and county ordinances and state laws totaling to
DU building construction.and hereby amhorim representatives of this city to enter upon the
above-mentioned property for Increment purposes.
fr-s W (We)agate to gave, damnify and keep harml.ss the City or Cupcnom against
N liabilium.judgmenu. Qpcsucs which may in any way acuue against tail City
U,z m eonsegmnee of th in of this permit.
^ APPLICANT UND A S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
Fd'7
SOURCE REGU S
V
Deb Re-roofs
H
Signature of Applica
HAZAARDOURDOU S MATERIALS DISCLOSURE Type of Roof
Will the applicant
imforumipal Wilding occupant❑9.1rehandle Health and
C echoedSm by the Cupertino Municipal Calc.Chapter 9.13,and the Health and Safety
Cork,&coon 35532(1)? 4
❑res �Ip'Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of future building occupant use equipment or devices which If a roof is instal ithout first obtaining an inspection,I agree to remove
it ha>ardous air contaminants as formed by the Bay Area Ail Quality Management all newmaterial r nspection.
District?
❑Yes �No
I have road the his, 'tats materials requirements under Chapter 6.95 of the Califor c
nice H. Sall ctiom 25505,1553)am125534.1 underwiM that ifthe Wilding J�
Pecs out ccion, y mans that It Is my responsibility m notify the neeupNl or the J (7
requirementsv, s bc_met,nor m isauame of a[mtifir ancy Signature Of pl ant Dale
Owner or authori< gent Date All roof coverings to be Class"B"or better