03010120 CITY OF CUPER't'INO na�'�a---- 'a "'"" '
BUILDING DIVISION PERMIT ;GONTRAGTOR INFORMATION '
BU I WIND ADDRESS: PERMI3'NO.
— 10357 WESTACRE DR 0';010120
NER'S NAME: APPLICATION SUB DATE
,DELPARASTARAN MEHRAN AND NAS I 01/22/2003
NE: SANITARY NO. CONTNOI.NO.
ARCIIITT:CT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
00 LICENSED CONTRACTOR'S DECLARATION
to
aP I hereby effirm Nat 1'..licensed under provisions of Chapter 9(commencing Job Description
G<� with Salinn 7gApnf Division Sof But Businessand Profwsione Crde.and my license is
ZO��< nfell mrceaedeffeet. ADD 70 SQ. FT. KITCHEN REMODEL
License Class LicO
F_1-uq Dam T'SDECL PINALED
g As idoIl WusS DECLARATION
1 understand my plans xhall he used as public records 13 2004
n ig W JAN
oup. Licensed Prommoinnal
OWNER BUILDER DECLARATION
wi<f I hereby affirm that 1 am exempt from the Contractors License law for the
no Following reason.(Section 703LS,Business and PrefesmonsCode:Any city orcounty BUILDING
n K$ which requires u permit to construct,alter,improve,demolish,or repair any structure
1,to prior it)its issuance,also requires the applicant lorsuch Permian rile a signed statement
o that he is licensed pursuant to the pnwtannsofthe Contractor's License Law(Chapter 9 Sq.Ft. Floor Area $25900tion
(commencing with Section Tight))of Division 3 of the Business and Professions Core)or
y $ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit ubjects the applicant to a civil penalty of
not mine than five hundred dollars($500). be Occupancy Typc
❑I.as owner of the property,or my employees with wages as their mile compensation.
will du the work,and the structs.is not intended or offered for sale(See.7W ,Business
and Professions Code:The Contractors License law dors not apply to an owner of 102 — PIERS
egmred Inspections
property who builds orientations thereon,end who decssmeh work himself.,through his
nvn employees,provided that such improvements am not intended or offered for We.If, 103 — UFER
however,the building or improvement is sold within on year of completion,the owner
builder will have the burden of proving that he did not build or improve our purpse oof 104 — REBAR
sale')' 105 — ANCHOR BOLTS
I.as owner of the proper, orexclusively contracting with licensed contractors m 106 — SEWER & WATER
onswct the Pmjen(Sec. Business and Professions Code:)The Convenor's Li
cemselawdoeano,app an miner of rope, who builds ori re vea thereon.end 202 — UNDERFLOOR PLUMBING
who cotrawts tr,nuc, ojecuwith c vacmr(s)licensed pursuanuo the Contractor's 203 — UNDERFLOOR MECHANICAL
Lice❑lamexnm sec. ,B&Pc V,thin amen 204 — UNDERFLOOR FRAME
Lt. e11 205 — UNDERFLOOR INSULATION
WORKER'S PENSATIONDECLA ON 301 — ROUGH PLUMBING
herehy atm.under penalty of Perjury be of the fellewing d,Ommmns: 3O2 — TUB & OR SHOWER
I have and will maintain a Certificate of Consent to wif-insure for Worker'sCompen-
eatinn,as Provided for by Section 3700 of the IaMr Code,far the performance of the 303 — ROUGH MECHANICAL
work for whichOf,permEisissued. 304 — ROUGH ELECTRICAL
❑ I have end will maintain Workers Cmeberealm.Iaamnce,as required by Senior, 3 05 — FRAME
3700 of the labor Code,for the Performance of the work for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number am: 306 — HOLDOWNS
c°Hier: P"limy"".: 307 — INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 — SHEETROCK
Glinsectiom ocean.,lteconallered iflhe permit is f^roncun
hamdanllimplI0 ) 309 — EXTERIOR LATH
irlcsa) 310 — INTERIOR LATH
1 evoly that in the performance of the work for which this permit is issued.1 shall net 311 — SCRATCH COAT
employ any peru in any manner to as c^me subject or Workers Compensation
Laws of California. he
.Dale 313 — ROOF NAIL
Applicant
NOTICE TO APPLICANT.if,after making this Ceni fcate of Exemption,you shoo ld 501 — FINAL ELECTRICAL ENERGY
hecome subject to the Worker's Compensation pmvisinns of the labor Cale,you mon 502 — FINAL PLUMBING ENERGY
O ,z forthwith comply with such provisions or this Formitahal l be deemed revoked.
7
CONSTRUCTION 503 — FINAL MECHANICAL ENERGY
q
work
whicby hOr, ermitissaed(SeeinnlcnCis.C.) ay Gmthe prinrmanccof 504 — FINAL BUILDING ENERGY
13i > thewersNameichthispewitisissucd(Scc.31yJ].Civ.CJ 505 — FINAL ELECTRICAL
W A Unaers Name
� z undrsAddreas 506 — GAS TEST
U O 1 cenify Nat I ban read this application andstem that the above information is 507 — FINAL PLUMBING
e., H correct.1 agree to comply with all city and county ordinances and stale laws relating to
O building Coast ion,andhcm yauthnreerepresentativesofthiscitytocnteruponthc 5 FINAL MECHANICAL
7+ � shove-(We at to as t.r sPeefinn keepha. O9 FIN MADE 11
(We gree to as emnify and kap harmless the City of CuPeninoagainst
Iiabilitie dgrom u std expenses which may in any wayatttucegainvsailCity 5 N G
U 7 in con once if, ti ng of this permit. —
LL77 APP ANTU ANDS AND WILL COMPLY WITII ALL NO -POI Issued byS 1 WORKS Dale
SO RCG NS. �A
r t.2' Re-roofs
gr, .re rrnpMomvanm Dine
HAZARDOUS MATERIALS DISCLOSUREf Type of Roof
Will the applicant or future building occupant more or h]odle harardous material
as defined by the Cupenino Municipal Code,Chapter 9.12,and the Ilealth and Safety
Allwod, ❑Yie.25532007 ❑N„ All roofs shall be inspected prior to any roofing material being Installed.
Will the applicant or future building mecmanl use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
I handlers air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
trio?
❑yes
I have r� thchevardt sniawriaismquimmenLsunwrChapwr6Y5oftheCalifor-
meHealth&5r Iy Curie, oto 8515,25533 ted 255311 understand ma if the boibung
does c fly is a ant.camili eryresptrsibilitymno,ity the+ cuIF t fthc
req which ton pnunnissuance nfa Cenificare ol0.cup ey., Signature of Applicant Dale
cro authunxcd gent ate All roof coverings to be Class "B° Of bC[lCr