06020088 CITY OF CUPERTINO ° ''' *+"�sw�:.aa�a.f, +'
BUILDING DIVISION PERMITiCONTRACTnR INk'OTtMA.TIQN
BUILDING ADDRESS: � PE0.Mn'N0.
10518 STERLING BLVD
itF.R'S NAME: PERMIT ISSUEDATE
BAHRAM SHAMLOU 2457 HUERTO DR 03/24/2006
PRONE: (408) 605-7777 SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
vOp LICENSED CONTRACTOR DECLARATION
I hereby affirm that 1.m licensed ander previsions of chapter 9(commencing Job Description
wine Section 7gMl)
in full force and effecoft.Division3OfMBuneoaMPpfussnsCod,andmylicnia NEW 1-STORY SFDWL(2917 ' --LIV. )
>q? License Class Lk.g GARAGE--4481
Data Consfactor
ARCHITECTS DECLARATION
w1 understand my plans shall m used as public records
e G Licomad Professional
g OWNER-BUILDER DECLARATION
<I 1 hereby affirm Nat I am exempt from the Contractor's License Law for the
-O o following mmon.(Section 7(n 1.5,Business and Professions Code:Any city or county
<m which¢quires.pandit to construct.sire,improve,dcmulim,nr¢pair any suucwm
c prior at i6 omicron.also requires[be applicant for such permit to Glc a signed statement
S
Nat he u licensed p..am to the promamu or the Contractor's License Law(Claque,9 Sq.Ft.Floor Area Val 1
x�$ thin
he is ting withthoreioad and of basis for o e aingc Business pt Profusion Cram)lmion or
�' .. that io is Dump( any
and the burs far be dinged eumant(a Any violation of
Section?than by any red dont fm a permit subjects the applicant Ire!civil penalty of y�
not mom than Gw,hundred eon.n($SfJp). 3 itT te'i Q Q Occupancy Type
❑1,as owner of Ihe pmperty,or my employces with wages as their sole compensation,
will tip the work,and the Swctime is not intended or offered for sok(Sm',7014,Busima`.
and Profusions Code:The Consmcme.License Law does not apply m an owner of Required Inspections
pmpaty who buildsoeimprnves thcmon,and whodoesaochwmk himulforthroup his
own employees,provided Thal such improvementsart ret mundkA oroffereA fpr sale IL
however,We building or improvement is sold within one year of completion,the owner-
builder will have the burden Of proving that he did not build Or improve for purpose of
sate.). �a!
❑1.as Owner of the propeny,am ex.tm iveiy contracting with licensed Contracm.mcera 'ate
contract she pmjea(Sec.7W.Business and Professions Code:)The Contractor's U.
res (N I LI �`'tit)
cease law does not apply to an owns of property who bailds orimpmwa uMMon,and, ( U
who contracts for such pMjeeu with a COMIOCtor(s)licensed pun tiIn the COntraclors
License law. fifty/�rytt(]
I am eaemp,under Scc. n Bk PC far this Masan
a t/ 4?Wf7
WOR •RATION DECLARATION
I hereby ar isRi under penalty of perjury one of We following declarations:
❑Ihsve and will mninaina Cenibeau Of COasenttoself-inaurt foe WOrtcYSCompem
cation,as provided for by Section 37M of the Labor Code,for Ihe perfonmene,of rbc
wark for which this permit is issued.
❑1 bare and will maintain Wnk es Compemauon Insunna,as rcquiMd by Section
37M of the Labor Code,for the performance of the work for which thia permil is Issued.
My Workers Compensation Irtannce prier and Policy number art:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section Cued not becomplcted if the permit is fnronc hundred Clnllars(SIOD)
or less)
I¢niN that in the performamc of the work for which this permit is bound.)shell not
employ any person in any manors,asmm ubjecu cWortrn'Cpmpewtion
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,a r making this Cc mate of&emotion.you ould
become subject to the Worker's ompcnution proviaioas of the Lahr Conic,you nest
J O fi MwiOt comply with such pro lMOns W this permit shall be deemed rewound.
Z y CONSTRUCTION LENDING AGENCY
PIheMbyaflirm Nal lhert is a Contamination hrdift.gene,for the pedormamcuf
f5 the work for which this permit is issued(Sec.3097,Co,C.)
QLmcm,'s Name
z tender's Add.
U C) 1 certify that 1 have read this application and sum that the above infmmmin.Ice
ly F correct I agree to Comply with all city and county oNinances and stare laws relating to
0 building construction.and hereby outhome repmsentaincs ofthis city to color upon the
ahovc-cs.judgm property for exiscoion purposes.
H a (we)agree to save,indemnify and keep hermleas the City of Cupertino!pins(
fq incoisequenc of ts.the wooing of ibis cewbich may in my way lttrvc against aid City
in consequence of the gnming of this oesmil.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIO
Re-roofs
Signilure ofA Idam/Cantractor pati
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wil the applicant or future building occupant store or handle haa4rdous normal
as Claimed by the Cupertino Municipal Code,Chapter 1.11,and Ihe Health and Safety
PC.Sick,.35532(¢)?
❑Yes ON. All roofs shall be inspected prior to any roofing material being installed.
Will the mplicam or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit heaardnua air contaminants m darned by the Bay Area Air Quality Management
District, all new materials for inspection.
Oyes ON.
1 hoot mad the hmallous malerialsrequiremenu under Chapher695 of tic Califor-
013Health6 Safcsy Code,Sections 25505,25533 and25534.lundcravW Nazifthe Wilding
does not currently have a team that it is my Mspm u,hility to nnufy the m<upanl of the
mquticau. hichmnt ?506r aomof.Cervibm,ofOccupanap Signature of Applicant Date
r— -- 3 Dir
Owner tar mtth ` d agent D,lo All roof coverings to be Class"B"or better