05080140 CITY OF CUPERTINO '? as� ,' 3->• "7"
BUILDING DIVISION PERMIT 'CONTRACTOR INFORMATION
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BUILDING ADDRESS: BEHROOZ ARAM PERMIT No.05080140
OWNER'S NAME: PERMITISUEDATE
BEHROOZ ARAM 10660
NE: SANITARY NO. CONTROL NO.
ARCHDEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT 0
PLUMB MECH
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X00 LICENSED CONTRACTOR'S DECLARATION Job DCS
1 Wrathy affirm mat 1 an liprovisiomis of CNptor 9(commcncfng P
with section 7MO)of DhIAM 3 of==and P aOr,Code.and my Ike=is
ImuforeeandefrecL TEMP POWER POLE ,
License Ctas Lae.0 Y.A6 R
Dato Comomm, 7 .r
ARCH17ECfS DECLARATION ®
I understand my plans shall W used u public records - f:JI%y V `"
5�0 7
g W Licensed Professional ...QQQ
0 OWNER-BUILDER DECLARATION
<i I hereby affirm Nu 1 am exempt from the Contrxcmr's License Law for the �l5
C o O following mason.(Section AD 1.5.Business and Professions Cole:Any city Or county ��V
5$ which requires a permit to construct,alar,improve,demolish,or repair any structure .3 0 0
tv^ PH.,Otto iauancc,alsu requires meapoicanl for such permit to file asigned suumcm
that he is licensed pursuant o the provialons of the Contractor's Liam Law(Chapter 9 Sq.Ft. Floor Area VJt• 4 -'Valuation
$ (commencing with Section 7000)or Division 3 of flue Business and Professions Code)or
Nu is,I.exempt therefrom and the basis for dm alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of g U Occupancy Type
not mom Oban five hundred do1Wa(ML
❑I,as owner of the property,or my employees with wage,as theirsole compensation,
will do the work and the ns structure u not intended oroffeoad ronak(Sec.7044,BusinBusinessRe aired Inspections
and Pmfea die;Code:The Contractor's License Law dors cot apply to an Owner of 9 P
property who Wilds Or Improves thereon,and who does such work himself or through his
own employcus,provided Nat such improvements are not intended Oroffered for oak.B.
however.the building or improvement is mid within one you of completion.the owner.
builder wit haw the burden of proving that be did nm build or improve fa purpose of
sou.).
O I.as Owner of the propeny,am exclusively contracting with licensed...tractms u
construct the project(Sec,7044,Business and Professions Code:)M Contractor's Li.
cave law dors not apply to an owner of property who builds or Improves themon,and,
who contracts for such projects with a conuantor(s)licensed mammal to doe Connowtoes .
Lkenw Law.
❑.l am exempt under see. .B&P C for this Munn
Owner^�fw?5GZ wnr2,a.-� Dau C9/fir
q:..
WORKPAS COMPENSATION DECLARATION '"• � - -� - -
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Catifiamof Consent o self-insure for Wmwes Compen.
cation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. ,
❑I haw and will maintain Worker's Compensation Innuance.as required by Section
3700 of the labor Code,for tire perferrnance of the wok forwhich mix permit is issued.
My Worker's Compensation Insu,ance carter and Policy number am:
Center. Policy No.: _
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Ibts mcden mad notbecamnpleted if be permit isforonchundred dollars(SIM)
or Ins.)
1 certify the,in the perlmonmce of In,work for which this retook ts Issued,I Nell not
employ any person in my manner an as to become subject to the Worker'Compensation
Laws of California.Dam
Applicant
NOTICE TO t-1LZd'2 —
APPLICANT.IL after making this Cenincam of Exemption,you Mould
become subject to the Worker's Compensation provisions of the Labor Code.you must
0 O fonhwith comply with such provisions or this permit shall M doomed revoked.
Z,TediCONSTRUCTION LENDING AGENCY
[=. I berehy,affirm that them Is a coawctinn lending agency in,me performance of
C4 the work for which this permit U issued(See,3077,Co.C.)
W�Q Lender's Name
Z Lender's Address
f,0 1 comfy that 1 haw read this applicuton and sum thm the above information is
fy^ mrren e m I agrecomply with all city and county ordinances and auto laws milting m
0 S`'J� building construction.and heroby authorize reprownmives of Our city to tutu urym 0u
` W ,taw-mentioned pmpcny for inspection PUMxxxL
(We)agree In uw.Indemnify and keep harmless the City of Cupertino against
,.y rA 0abithies,Judgments.cats and expenses which may in my way xccsuc agalnslWd City
V 7 in consequence of the Starting of this permit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date /7—or
SOURCE REGULATIONS.
signuu _! 1I'T'05E Re-roofs
re. rontit f�
Dam T
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or future building occupentsmseo,hmodle hsvardous material
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
otic,section 23332(a)1
Yo, Fd No All roofs shall be inspected prior to any roofing material being installed.
❑
Will the applicant or future budding Occupant tree equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It harafdoa a,eMmentunts as denned by dm Bay Area Air Quality Management all new materials for inspection.
7dox,
❑Yn1 have mad the husatdnusmateriahrequi ernmets underChapterG95 Ofthe Califor-
Hcolth&SafctyCode,Sectimts 25505.25533 and 25534.1 uummund thuirthe building
not currently haw a unset,mu it u my responehility to omtify me Occupant M the
uiremcnu which main be mel prior to issuance ofd Cenifmato ennaney. Signature of Applicant Date
All roof coverings to be Class"B"or better
ner or authodxd agent Dam
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
aCO Fax(408)777-3333
UPEI�TINO
Building Department
JOB ADDRESS: PERMIT# �S-u 8c G J
V36 Tocv. Wa- ^rkz CA-q5-c)14 .D59-6 oke
OWNER'S NAME: PHONE # Leo B- 0 6 3
GENERAL CONTRACTOR: FAX# Le o8- 2c,75
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
60 SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
T EMP POWER 0S
UPERTINO PERMIT APPLICATION FORM
APN# 3—IDate: $/`-T/os
5 —3-7— c56-7Building Address:
F d —rte, � , Cotv , 4 r
.Owner's Name: Phone#:
�i�nc Z
t+-O& — 6— 6
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
G -
Building Permit Info:
Elect ❑
Job Description:
Residential A Commercial ❑
Cost of Project:
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
7S-7
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform
A. All the work authorized by this permit
B. A portion of the work
C. None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
• portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
PersorVFirm Address/City Phone Number Type of work to be
erformed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse side).
Property Owner's Signature: Date: / � 7/o-
Job Address: 4 0 (2(g2 Min Ar,- r YR C/ Permit# O do 6 O (1 �
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
DeRaarbnent.
•
City ,of Cupertino Building Department '
CITY , 10300 Torre Avenu
CUP ERT I NO Phone: (408)777-3228
Dear Property Owner.
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit. Building permits are not required to be signed by property owners unless they are
personally performing their own work. If your work is being performed by someone other than yourself,you
may protect yourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information.for your benefit and protection
If you employ or otherwise engage any persons other than your immediate family, and the work
(including materials and other costs) is$200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding,federal social
security taxes,workers compensation insurance,disability insurance costs,and unemployment compensation•
contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers' compensation insurance.
. For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish,the U.S.Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed contractor or
subcontractor,only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit,erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors State License
Board in your community or at 1020 N Street,Sacramento,California 95814.
p
Please complete to and return the enclosed owner-builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
Building Department, •
City of Cupertino
Printed on Recycled Peyer