04120131 CITY OF CUPERTINOn
BUILDING DIVISION PERMITCpIVTReCTUR xNF`OItNIA'CT4�, V
BUILDING ADDRESS: - KHURRAM IQPr'"N'b4120131
NE0.'S NAME: SC PERMIT ISSUE DATENE: SANITARY NO. CONTROL NO.
ARCHOECI7ENGiNEER: - BUILDING PERMIT INFO
BO EO PLO O
MECH
o6 LICENSED CONTRACTOR'S DECLARATION JobDescri tion
1 lemby affirm that 1 am licensed under provisions of Chapter 9(commencing P
mMection 70011)of Division 3 afdic Business and Profession Code.and my license is
infull rorcaandercem.
Lignac Class a LM.« SFDWL-2 STORY (3505 LIVING)
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Dam Commctar GARAGE 475 SQ. FT.
ARCHITECTS DECLARATION
1 understand my plana shall be used as public words
l� Liceumd Professioasl
OWNER-BUILDER DECLARATION
tri�I I thereby Aft m Net 1 am sacmpt from the C.mmemrs Licence law far the
S:00 following reason.(Section 703 1.5,Business and Profession Code:Any city or county
+�$ which require•permit to consumer,alter,improw.demolish.w repair any suuctum
prior to its Issuance.also requires the applicant for such permit ve file a signed comment - -
< timheulicensedpursuanttoMeprovisiwuofdxC.SumecoHslicenselaw(Chapter9 Sq. Ft. Floor Area V2"OU 750
1 (commencing with Section 7000)of Division 3 of one Business W Profession Cadc)or
IC
that he I.eaerepl therefrom and the basis for the alleged eaunpdan.My Weldon of
Section 7031.5 by any appilunt for a permit subjects the applicant to a civil penalty of APN Number Occupancy T
not more Nut fiw hundred dollars(11500). P Y YPe
01,a owner of Mass Property.or my employes with wages as their sole compewdon, 36617105 . 00
wiB do the work and the Suuclun 4 sol Intended or offered for sale(Sec.7044,Business
and Profealn Cade:The Contractors U.Law does rot apply to an owner of Required Inspections
properlywho builds orimprowthereon.and whodoessuch work himself or through hl
own employes.provided that such improvements art not intended oraQered for We.If, f f3
builder,site building orimprovementwithin ane year of mproefor pun.
owner- 'J�,�I,�\ ��jj �®
builder will haw the harden of proving that he did not build or improve for the am of i'Jr-' j+f'\\\ �) 64tily
pie.).
Q11%s owner of the property,am exclusively contracting with licensed cantrsetors to
construct the pmjecl(See.7044,Business and Prufesdans Cade:)The Commutes Ll. O�/
cents Law dors not apply 0 an owner of properly who build,or improve thereon,ad, 20iIC
who contracts for such pmjecu with a conuactor(s)licensed Pursuant to the Contest �!/ssll
License law.
Ie., lundu See. -.B&PCFa,IhUoUMm
Data 7
WORKERS COMPENSATION DECLARATION BUSO W11; _'_.,
1 hereby Anon under penalty of perjury,arc of the following dcduulm e
or
hsw end will ammuln•CW fiete of Covent an pIf-ieurt far Wormer Campcn.
nation,as provided for by Section 3700 of the labor Cade.for Ne Performance of the
wart far which this permit is issued.
0 I haw"will maintain Wastes Compewdan Iruu ..as requited by Section
3700 of the Labe Code.for the petfarmane of the work for which this permit is Issued.
My Workers Compensation Nunnce carrier and Policy number are:
Carder. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Section need not bucompIcw trim permit Isforo a hundred dollar($101)
or kcss)
1 certify that In the performance of the work for which this permit b turned,I shall not
employ any mount in any meopefigplm bnome Subject to the Workers Compensation
Laws a.CAifo'd pen
Applicant
NOTICE TO APPLICANT.11 I L Ams making this Certificate of Exemption,you Should
become Subject to the Workers Compensation provisions,of the labor Code.you must
z forthwith comply with Such provision or this permit that be decmW revoked.
zO CONSTRUCTION LENDING AGENCY
F I hereby alllrm Nn Vert Is a cotuuuction lending agency for the Performance of
pGNe work for which this Permit 4 30
deissued(Sec. 91,Civ.C.)
C6
Q
Lenders Name
U z Lenders Addrom
U O 1 ratify,that i ban read this application"sum thus the Show information IS
Iia t~ corrin I gree to comply with At city and county ordinances and atom Ian rcbdng M
O U building construction,and hereby amhodre mpreanutiws or aids city to enter uponNc
W .leve-mentioned property for IMPection PMFwL
p1. (We)agree to taw.Indemnify and keep harmlea the City of Cupertino against
rU N liabilities.judgmenu,eau m
and expenses which may in any way seems,agsint aid City
Z in comequenceof the granting of Nis Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE LATIONS, r7
,�o✓v� 1� y . 2 141 o Re-roofs
"Inalurc of ApplieanVContnemr Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fume building occupant sane or handle hanardous matedai
as defined by tho Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Code, 35525532U)?Oyu kO
All roofs shall be inspected prior to any roofing material being installed.
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Will the applaanl or future building occupant use equipmem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haerdous air centamlasms as defined by the Bay Area All Quality Management all new materials for inspection.
District?
❑Ye Nu
Ihave mad the hnaNtmmsmrialsrequimm uunderCNpmrd.95 ofde Califor.
me Health I Safely Cade,Sce9ons 25545,25533 and 35534.1 undusuM that lflhe building
des net c tly In, a enN4 that Il 4 my responsibility to toddy the aLTuPanI of dK
rtyulre n ichmustbe at poortofssuanceofaCenif of
Signature of Applicant - Date
S"a1 All roof coverings to be Class"B"or better
Owner tar awhariwd gcto Da