02110099 Cl'1'Y OF CUPER'1'INO 1� " as
Buu,orrvc olvlsn3N PERMIT CONTRACTOR INFORMATION
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BulQ*QAS0BEsSTERLING BLVD AYUB KHAN PERMIFN02110099
OWAig"R411:KHAN 10251 STERLING BLVD APPLICATT1`pgi4Ty2002
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IFTONE: SANITARY NO./ CONTROL NO,
ARCIRTECTIFNGINELR: BUILDING PERMIT INFO
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p0, LICENSED CONIRACfOR'S DECLARATION
°F IherebyaffirmthatlamlicensedunderprovisionsofChapter9knmmcncing TEMP POWER lob Description
sin wish Sectio^�IMX 3nf Division3ol Ne Business tortZfessions Col and my license is
��H in full lora ailyYTffecl. JU
OZ✓MZ hicnrm Clu Conn T7=r
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F'='t-� ARCI oTiCTS DEC ATIO
�915 I ebtem,my piens for)he medals public eceofds
apyatU
�LLl� LicensedProfccsional
OWNER-BUILDER DECLARATION
a<S I hereby affirm that 1 am exempt from the Contractor's License Low for the 6 1 O Q
w fallowing reason.(Schon 01131.5.Business and Professions Code:Any city memory
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°'sac m which mquife.i a permit b)construct,alter,improve.demolish,or repair any Somcturc
if Prior it)its issuance,also requires the applicant for such permit to file a signed statement
lj?< That M1c is licensed pursuant to the provisions of Nc Contractor's License Law(Chapter 9 3S45B15l0de8A&0 Valuation
,i=Q (commencing with Seelion9(XXBof Division 3 of the Business and Pmfessinns Cod)or
a _ Nat he is exempt Nerefrom and Ne basis for the alleged exemption.Any violation if
Section 9031.5 by any applicant for a Permit subjects the applicant to a civil readily of i JAPNN Occupancy Type
not marc than fin hundred dollars a5an. 304 - ROUGH ELECTR CAL
I,as owner of Ne property,or my employees with wages as Ncir sole compensation,
will do Ne work.and be suoccure is not intended oroffcred for sale(Sce.904<,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q P
property who builds or improves thereon,and whodoes such work himself or through his
own employees,Provided Nat such improvementsam not intended orolfercd for sale.If,
however.the building or improvement is sold within one year of completion,he owner-
builder will have fee burden of proving than he did not build or improve for pa,nsc of
sate.).
1,as Owner shepot ct(See.
.B exclusively contracting with fieTMed contractors i
next La des project(See o an Business and Professions Code:)The Conmm ars nd
who lawcocaoatapply jean ownerof Property who buildsorimproves Counselor's
License
1
License facts for such Pmjcc¢with antmrannr(s)lian¢J pursuant to the Coneanor's I /
License Law.
❑lam cacmPt under Sec. .B&PCfor Nis reason 2�X�
Owner Dale41 V/
WORKER'S COMPENSATION DECLARATION r)
1 hereby affirm under Penalty of perjury not of the following decimations!
1 have and will maintain a Ceraticate of Consent to sel6lnsum for Workei sComp:m
cation,as provided for by Section 39(X)of the Inbar Code,for the performance of the
wark(of which this peanut is issued.
❑1 ban and will maintain Worker's Compensation Insurance,as required by Section
37I0(if Ne Labor Cialf,brNe Performanc�e ofit 9wnrkfur which this Permit is issued.
My Wnkcr' Compc atin//n''Insufancc cartRnq[Pulicy numberam:
['s YdXtl� P✓✓✓✓olicy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This.See ion need not be completed if the permit is for one hundred dollars($100)
Ices.)
I certify That in the rerfortnanee of the work for which This permit is issued,1 shall not
employ any person in any manner so as it,become subject to the Workers Compensation
Inwsof Califomia.Data
Applicant
NOTICE TO APPLICANT:11,after making this Cenificahe of Exemption,you should
become suhjen m the Worker's Compensation provisions of the Inbar Code.you must
O O forthwith comply with such provisions(it this Permit shall he deemed revoked.
Z y CONSTRUCTION LENDING AGENCY
P1 hereby affirm Nal Ncre is a Construction lending agency for the Performance of
ly' 7 the work for which this permit is issued(Sec.3007.Civ,C.)
{31 Q Lender's Name
0, Under's Address
U O 1 certify Nal I have read this application and state that the strove information is
{I. ,r correct.1 agree to comply with all city and county ordinances and Some laws relating to
p U building construction.and hereby anthonic representatives of Nis city to enter upon the
above mentioned property for inspection purposes.
1 (We)agree to save.indemnify and keep hafmless Um City of Cupertino against
tiN liabilities,judgments.costs and expenses which may in any way accrue against said City
U In conscqucnce of the granting of Nis Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY Won ALL NON-POINT Issued by: Date
SOfIRC R%iGU;ATIONS. 1 /
� ,mic OC.O ono Re-roofs
Swe"' ApPlicaHAZAR nor / Dam
"'CC// cAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Neapplicantnr future building Ie.Chapter
Aareorandhandle rearduusmaterial
az defined by the Cupertino Municipal❑MC.Chapter 4.13,and she IIC]IIM1 and Safety
Code,Section 25532Iay! All roofs shall be inspected prior to any roofing material being installed,
❑Yes ha Na
Will thea applicant or future building men t use mem or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Pp s t pan quip
emit loommits air contaminants as defined by the Bey Arca Air Quality Management all new materials for inspection.
District?
C]Yes f7Na
1 have mad Ne hovasdous matefialssequimmen¢umbr Chaper 695 of Oe Cantor
nits IIcaIN&Safety Calc,Sections 255115,25533 and25534.I understand Nat if Ne building
does not currently haw a tenant,Nat it is my responsibility m unify be occupant or the
mquimmemswnmy mm pipnn issaanmafacpN r(xreaPaney. Signature of Applicant Date
..A�' All roof coverings to be Class "B"or better
oamerN Nth.r,,rd agent Dale