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CITY OF CUPERTINO
CONTRACTOR
BUILDING DIVISION PERMIT
INFORMATION:
❑UILDING ADDRESS:
PERMIT NO.
19080 STEVENS CREEK BLVD
OWNER'S NAME:
APPLICATION SUB DATE
HUMAYUN KABIR
01/24/2003
Nli:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
_BU ILDIN ERMIT INFO
_
PLUMB MUCH
Wil
0
LICENSED CONTRACTOR'S DECLARATION
b
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
e ripe
with Scctinn ]IXXB of Division 3 of Ne Business and Professions Cook, and my license is
-
In full bsrec and clmn.
TI
License Class Lk. X
Date Cmiumemr
t
ARCHITIiLTS DECLARATION
ATION
1 unJerannd my Phns shall M used as public
Licensed Profcs umill
OWNER-BUILDER DECLARATION
1 herchy affirm that I am caempt from the Contractor's License law for the
following reason. (Section 7031.5. Business and Professions Codc: Any city Or county
which requires a Permit m construct, alter, improve, demolish, nr repair any Structure
prior of its issuance, also mill the applicant lot such pemfil to life a signed sulemeni
Nat he is licensed pursuant to the Provisions of NC Cuntmcmr's License Law (Chapter 9
Sq. Ft. Floor Area
$Y00tion
(commencing with Section 7") of Division 3 orthe Business and Professions Code) or
Nn he is Camara therefrom and the basis for the alleged cumption. Any violation of
Occupancy Type
Section 7031.5 by any applicant for a Permit subjects fire applicant 10 a civil penalty of
not more than five hundred dollars (55110).
❑ I. a owner of the property, or my employees with wages as their sole compensation,
— ROTJ
will do life wok. and theamnae is not intended or offered for sale(Sm. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
501 - FINAL �Wo�'NERGY
pmpeny who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements am not intended or offered for sate . If.
505 — FINAL ELECTRICAL
however, the building or improvement is salt within one year of completion. the owner
builder will have the burden of proving that he did not build or improve for purpose of
stale.).
b1, as Owner of the property, am exclusively contracting with licensed convention to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cents Taw does not apply to an owner of property who Wilds or improves thereon, and
who contracts for such projects with a contractor(a) licensed pursuant to the Connector's
License Law.
❑ 1 am exmpt under Sec. B & P C f 14Z
��WORKER'S COMPENSATION DICN
I hereby affirm under penury, of perjury one of the following declaration:
nave and will maintain a Certificate or Consent In self -insure for WorkcrsCompen-
Ban, as provided for by Section 37M of the labor Code, for the peRnrmance of the
work far which this permit is issued.
❑ 1 have end will maintain Worker's Corer iduci ion Insurance, as required by Section
3700 of the labor Code, for the performance of Ibe work for which this Permit is issued.
My Workers compensation Insurance carrier and Policy number an:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if de rermit is uronc hundred dollars (5100)
less.)
I cenify that in the Per Of once of the work for which Nia permit is issued, l shall not
employanyre manner ajt�r �jgOt Ne WOrkers'Comrensalion
Laws of Califor' I V
Applicant
OTI E TO APPLICANT: If, after making this Cenificau Of Exemption, you ahnu1J
e subject to the Workers Confrontation Previsions of the Loan Code, you mat
fn b 0th comply with such provisions or this Permit shelf M deemed evoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ, C.)
Leaders Name
L et der'. Addass
I certify that 1 have read this application and stale that the ahuve imunditdon is
coeect.l agree to comply with all city and county ominsnces and slate laws relating to
e
and hereby suthonp rposes. es of Nis city m emcruryfn Nc
buildingcotioned
ro for inspection)
ahuve -(We)a
keep ha.
(WC) agree m save, indemnify and hamlet the City Cupertino against
game
o
expenseswhich may in any way acme against said City
which
incoisequ consequence of thecostsand
AAPPLICANT of the granting of this permit.
APPLICANT UNDERSTA DS AND ILL COMPLY WITH ALL NON-POINT
Issued by: Date
SO RUE n y e
L
Re -roofs
Type of Roof
C plican.. .. .
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Ihalth and Safety
Code. Section 25532(a)7
❑ Ycs ro
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the appicant or future building Occupant tau equipment or devices which
it haardous air contaminants as defined by the Bay Area Air Qual ity Management
all new materials for inspection.
trier?
❑Yea wjo
I have read the hamNous`materials requirements under Chapter 6,95 of the Califor-
nia Health & Safety Cade, Sections 25, 5115, 25533 end 25534.1 understand that if the building
does ton currently hale a tenant that it is my msrysnsihility to notify the occurrent of the
requircemmusiallich,ad atfemetran toissuaceOracerafica rOeeupaney.
Signature of Applicant Date
All roof coverings to be Class "B" or better
raahoricd agent ate
N