04050092 CITY OF CUPERTINO 3
PERMIT G�ONTRAQ OR INF4RMATIO
BUILDING DIVISION rs cw � �A,s
BUILDING ADDRESS: PERMITNO04050092 4(]S O O 92
850 WIMP.RLICH DR
OWNER'S NAME: PERMIT ISSUE DATE
MISAMI MOHAJERTOBRIZI E: SANITARY0. NTROL 440.
ARCHIT iC rENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
38ij LICENSED CONDUCTOR'S DECLARATION JobDescri tion
M1 Mrcby effuse Nu I Am licensed under provisions of Chapter 9(commamcing P
with Section 700D)or hislon]ofthe Businasand Pmfemmns Code,aod my license
immAaforce endercer NEW 1-STORY SFDW (2828 SQ.FT. LIVING SPACE)
Is Damnm Clw connector -
u l ARCNITECT i DECLARATION GARAGE 4 4 7 SQ. FT.
FT.
I understand my Puns still M uvA As public meads FI
3�Ird Licensed Professional ,(fp (f
OWNER-BUILDER DECLARATION idas�$ep/A�®
02 1 MrtM1y.(Rene on I eusin from the Conuac,00 e:My c Law for the
%o o following wan.(Section 701J,ace Businessland and improve.
dem t Code:My oily or county
v�$ whish its int•permit re tees Me eller,improv,de permit
1 m repair ed anuctam
pow miucensed 0.tlmeequleslbovishowapplicant fanuchpennit.leen LA. comment
C that he(comma licensed pSesuam lame of Division
of Ne Cont(umossanccne law Chapter Sq.Ft.Floor Area r}sA�,e Valuation
$ Mahe is'exemOff pth Smllon7andthe ivuion]oflMeged eaanton.My fabrication Cade)or (U 9
33 Ino he u esemPt dr�efmm and the btu fm ds ailc6d exemption.My violation of
S Amon 7071.5 by Any Applicant for a Permit subjau the applicant in a civil peulty of All Number Occupancy Type
nal mom than Ew hundred dollars IV&
�f r
0 Lo townerofma pmmuc may employee wimwaguuelei(sec.7W.Besation.was j{ -
wiBdoumworkende: he Comunots License
.11cLaw es tons
10an anoru Required Ins Actions
and Profehons Code:The Connectors acute law dot nark apply m an awnsr of
is - q P
pmpenylone MIIdsviimprowa thmeogand who arsessuchwankHimselfor for We nu
awn employee,provided mel such Impmwmant art netlnunded maBeed for member If.
It wt Ne builtling mimprowmantis mid wiNin onetear of complWan,the owncn
bei r will have View of Proving Bal he did wt build or Improve for purpose or
As owrrr of tM prepeny.Am exclusively connecting with licensed cuntrsums m
co s Or project(Sea 7044,Business and Professions Cade:)The Contncmel U-
cane law docs not apply m an owner of proper who builds or impmw Bacton,and
who contracts for such pmJeae with a contractor(s)licensed pursuant o the Contractors
Luer Law.
❑lam Axe .-M Sac. .B hPCfo thb
lCamm
meOMPENSATIONDECLA1M � ser pefWty of perJury oro or the fallowing dmluhou:ase and will mainWn a Caniftcam of Corm m Uff-ha ce fmworkersCompen-
u provided fm by Section 7700 of me labor Code,fm the performance of the for which this permit le Issued.
have and will maintain Wmecrs Compensation Insurance,u required by Section
of the Labor Code,for the pclfo(manm of du work for which this permit la Issued.
Workers Compertion Irrance carrier and Policy number am:
Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
TITlssecBm need not becompleud If the permit islmam hundred dollua($100)
or less)
1 cenify met In the performance of the work for which this Permit is issued,I shall nos
employ any person M my manmrm As in become subject to the Workers'Compeuadon
Lewes of California.Dau
Applicant
NOTICE TO APPLICANT:If.aMr making this Ceniflcau of Exemption.you should
become subject an me Worker's Compensation provisions of Be Labor Code.you mon
O O forthwith comply wise such pOnumns or this permit shall be deemed revoked.
ti CONSTRUCTION LENDING AGENCY
I--I I herby e1Rrm that mem its construction lending agency for the performance of
G:> Br work for which this Permit is issued(Sx 71197.Civ.C.)
Wh Q Loonmes Nuns
7 z Lenders Address
U0 1 certify that 1 have read this application and sum that the above Information is
U,!-r coned.I agnea an comply with all city and county ordinances and esu a laws mining to
CISJ^ buildinicon did mbyaumorinamnewmuticaofthucilymcrtrupnnme
fbl above-men nd yfor iospcction PurWseA
CL
e)agree Io e,indemnify and kucp hanmless the cky of cupcnirm Aga ut
ti f/J liebili ,Judgmen ossa end experswhirh may In any wry same against said City
V 7 in ca qucncao egnmin f spermit.
F7 ANTU AND WILL COMPLY WITH POINT Issued by:qjtQ�&o Date
SO R REDO
Re-roofs
Sigi P Alacser Dam ,
AROOUS ding=LSDISCLOSURE Type of Roof
Will the cantorfutue IWiTERIA SDISCL SURE huardom maudal
u tlefrned by Br Cupemno mu pal Code.Chapel9.11,and IM Health and Sercty
Cotle,Section 15551(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
1,
Will
w IM applicant o fnuro b (ding aceupem use cyuipmanl ar Bcvlces which If a roof is installed without first obtaining an inspection,I agree to remove
It hamrdnu air contsminanu u fined by Bm Bay Area Air Quality Management all new materials for Inspection.
uin7
❑Yes u
I have Nebo m dalsequiemenuunder Chepur6.95ofine Califon
nia Hcalth afetyCodc tions155(15.15 77md15531.lumlcremndmulf Lh Milding
does not c ntly hew rn_4 the,it is y respomihill y m moil'y the up of me
requirt n Ic to
me prior uatrc are ficamo c n. Signature of Applicant Date
owner r amort, I ar All roof coverings to be Class "B"or better