03030030 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFO1NR I N ;
BUILDING ADDRESS: JAHAN CONSTRUCTION PERMITNO.
18831 TTT.,qQN AVE Q�Q20C)3n
OWNER'S NAME: 200 BURNETT AVE PERMITI.SSUBDATII .
SHEVA NEINAVAIE
NE: (408) 782-3102 SANITARY NO, CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
- O EO PLUMB 0
39i; LICENSED CONTRACTOR'S DECLARATION .Job Dl tion
vd 1 Mmby aescrp
ffin Nn 1 am liconaed under provisions of Chapter 9(commencing
wt Sudors 0)
Waf Dlvidon3offt aid ProRWnru Code sodmyllcemels
itfull f^nzd m TEMP POWER POLE
j kg.? LiLicenseClu•• 1k.#
? DateARCHI(ECTSDEC ARAT10N -
1 understand my Plena shall he used u public
room ds
Is� Licensed Professional - -
Oat I am exempt fr DECLARATION �.
E0 f I Mmhy.(Sec than 1 1. exempt(rum the CnnonsCo Uccnsa law for the
O o which
reams.(Suitt 7031.5.Business and improve.
t roll Code:Any oily or county
$tai which requites•permit re cnnoraL altar,MProse,tlemunit t ri e a sir ttrmmm
Et prim m its isswnce,dm requires the IM aspirant for such scuo m file s signed(mtemem
£ 01haonmenccemcJPurstion'I MProvWonofaftheBlrmessandcnactaw(Chapur9 Sq.Ft.Floor Area $`F y@tion
(mm a 1.exeog;exempt
Satiuren and the
basis f r th the alleged
exem t Protesilon.Anynru Codc)of
'}I a.• Nel he is evempi Ncrtfrom and iM bub for the alleged ewmptlon.Any vlol•don of '
Section 7071.5 by any applicant for a permituubjecu the applicant to a civil Nosily of 3 7&u,e41u—tffi0rO 0 Occupancy Type
not mem than an hundred dollars(8500).
❑1,u owner of the pmpmy,m my employcea with wgu u NeUmle mmpewtlon,
will do thework.andthe UmChm LL notintended or offered for ask(Sec. Bud^••• 1 U.3 — R 1 Cd In ec ons
and Profession Code:The Contrame.License law does fit apply m Courser ner of 304 - ROUGH oTR YFApL
property who build.or Improwa themoq and who der�uc h wink himsol f or through Ms
own cmployeu,provided that such Improvements art natlnunded moffemd fmsale.IL
however,the building err Improvement Is sold within one year of cumpledon,the comm.
bulkier will have the burden of proving that he did not Mild or improve for purpose of
sale.). .
LI 1,as owner of the property,am exclusively contracting with licensed convacWn Or
construct the pmjan(sus 7014,Business and Profession Cade:)The ConlraelorY Lt.
"me law docs not apply to an owner of property who Milds or Improves Charter.and.
who Contracts for such pmjccu with a contractor(s)licensed pursuant to the Cottrsmoes
Lice.taw. -
❑lamexemptptt oder S/g,., re
BAr P C for this ason
WORKER'S COMPENSATION DRCLA
I hereby affirm under penalty of perjury oro of the following declarations: -
I have and will maintain•Cenificm,of Consent to ulbimure for Worker.Compen-
inion,u provided for m
by Seon 37M of the Labor Code.for the performance of do
work for which this Permit is Issued
❑1 haw and will maintain Workers Compensation Inunnce,as required by Section
3700 of the labor Cade,for the performance of the work for which this permit la isaaed. -
My Workers Compensation Insurance carrier and Policy number am: "
Carder: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Irish mein need not M completed if lM permll LL two=hundred dollars(SIM)
Or Icer.)_
I certify Chat In tis p�rfnrmaue of the work for which this permit ts issued.I shall no
employ anype Idgnymm, lRM'2! ubjutto tM Workeri Compenutlon
Laws pf Calif e.pa�6[OL�^- /IG(��'C
gppli
NOTIAPPLICANT.If,ar r making this Certificate of Exemption,ynu.h^uld
Ise olh .uhjcet to the Worker's Compensation provisions of the IaMr Code,you must
.J Q forthwith Comply with such provisions or this Permit shall M deemed mookcd.
CONSTRUCTION LENDING AGENCY
I hereby a(Iirm that there Is a mvlructinn lending agency for the performance of
Ci the work for which this Permit Is issued(Sec.3097,Civ,Q
W� Lmdcr'e Nurse
Q z Lenders Address
V Q 1 certify that 1 ban mad this application and mate that the show InformaRun la
ly F+
Correct.l agrte to comply with all city and county ordinances and state laws mlating in
Q C.1 building construction,and thereby suthrum,mpremnuolves of this city to enter uptn to
If] move-meminned property for inspection purpose,
(We)agree to saw,indemnify and kap harmless the City of Cupertino g•insl
A IIab1111iu,judgmenu.cnata and expenses which may In my my xeeruc against old City
C) IA^PPLI94KT of the UNDERSTANDSor this AND WILL COMPLY WITH ALL NON-POINT Issued by: Dat �
SOUR REOULf.T10N�r .c / Of
7
E' Re-roofs
"um of APPli HAZA HAZARDOUS MATERIALS DISCLOSURE Ccournnor Dau Type of Roof
Will the applicant or future building occupant more or handle hacardous material
u defiled by Che Cupertino Muni I Cod.,Chapter 9.13.and the HGI h and safety
Code,SeNn 35333 WT All roofs shall be inspected prior to any roofing material being installed. -
❑Ye. I a
Will the applicant or for...buil 'ng occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hacardous air contaminants ss recd by the Bay Area Air Quality Management all new materials for inspection.
District?
GYcs Nu
Ihnc reed theharaMw.materials requirements under .Pur 6.95 of the Gl
nLLFIUIN&Sa¢tY aM,Semimu23505.355JJ anU 353N.1 undo dthss iflM building
Jena not curmntl a Immo Wt 11 LL my rc.penslhillty b noJ pant of the
myulr(m�ns wit vatM Pdmmluu�ncc ofa CcnlDu � Signature ofA Applicant Date c3 g pP All roof coverings to be Class "B" or better
Owner onuthodzcde cm Drs¢