03090176 (2) CITY OF CUPERTINO •- % .+
BUILDING DIVISION PERMIT kCONTRACTORINF'ORMATION
BUILDING ADDRESS: ADAM ASKARI PERMIT"103090176
'R'S NAME: PERMIT ISSUE DATE
PHONE: - SANITARY N0, CONTROL NO.
ARCHITECT'/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
log LICENSED CONTRACTOR'S DECLARATION
£,w,F Ibereby storm that l am licensed under provisions of chapter 9(commencing Job Description
xx`uf with Socism 7fAM))n(Division Sof On Business and professions Code.and my license is
in full force end effect.
3LlZ License Clue Lica REVISION--IN HOUSE USE ONLY
Dam.Contractor NO NEW PERMIT ISSUED/ ORIG. #
ARCHITECTS DECLARATION
I u I understand my plans mall be died as public records
Sad Licensed Pmleasionel
,n3 OWNER-BUILDER DECLARATION
I 1 hereby alTom that I am exempt from the Convector's License Law for IM
00 fallowing reason.(Section 7131.5,Business and Professions Code:Any city or coumy
�$� which requires a permit"construct,alter,improve,demolish,or repair any structure
in prior to its issuance,also requires the applicant rouuch permit to rile a signed statement
C that he is licensed pursuantmtm,nevisinnsnfthe Contractor'sLicense liw(Charter 9 Sq. Ft. Floor Area Valuation Q
22 zC (commencing with Section 7000)of Division 3 of the Business and Professions Cobi)or
`3$
Out he is exempt Ne,from and the Eases for the allcgW esemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 AN 4NOIBEef 0 0
not more than five hundred della.($50d). Occupancy Type
---
❑I.as owner of the property,or my employees with wsges at their able compensation,
will do On work,and the awmure is not intended or offered for talc(Sec.7044.Business Regg d
and Professions Code:The Convector's License Law docs not apply to an owner or 101 - FOUNDAT 1�{ Inspections
property who builds or improws thereon,end who docssuch work himself or through his
own employees,provided dint such improvements arc not intended oroRered for sok.If. 102 - PIERS
however,the building or improvement is mid within One year of completion,the Owner-
builder will haw the burden of proving that la:did not build or Improve for purpose of 103 - UFER
i1e)' 104 - REBAR
1,a Owner ej the property,am 704.Bexclusivelysinend bdin.etins with:)[Coed contractors m -. ..
construct Me project(Sec.7044.Business end Pre(essiom Code:)The Contrmmr',Li- 105 - ANCHOR BOLTS
come Law docs not apply to an owner of pmpeny who loud,or improves the"on.and. 106 - SEWER & WATER
who contracts for such projects with a coma bir(0 licensed pursuant to Me Contractor',
License Law. 202 - UNDERFLOOR PLUMBING
Iamescmp under .H&PCfarthis"asap 203 - UNDERFLOOR MECHANICAL
Data23-1) 3 204 - UNDERFLOOR FRAME
WORKERS C SATIOND ATION l -
Iherebyair,. Iserpenaltyofperjuryomb fonowingdeeluationa: 205 — UNDERFLOOR INSULATION
❑I have and will mainutina CeniOrneofcouenuomlf-iuum for Workeb Compcn- 301 - ROUGH PLUMBING
nation,an provided for by Section 3700 of the Labor Code,for the performance of the - 302 - TUB & OR SHOWER
work for which thin permit is issued.
❑1 haw and will maintain Worthies Componsatiun Insurance,an required by section 303 - ROUGH MECHANICAL
37M of the Labor Code.ror the crformorma of the work for which this permit is issued. 304 - ROUGH ELECTRICAL
My Worker's Compensation Insurance carrier and Policy number am: 305 - FRAME
Cartier: Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' 306 - HOLDOWNS
COMPENSATION INSURANCE 307 - INSULATION
(This mctmarmed not Mcomple"dEthic permit is fmmm hundred dolla.(SHID) 308 - SHEETROCK
oNess.) 309 - EXTERIOR LATH
employ cenlfy Matin the performance of the woh for which Min permit rk issued,I aura nm
Lamoanyperson inany manner mumxcbma subject in the worths.'Compenne0on 310 — INTERIOR LATH
w'i`^Ctlifornia.Dem 311 - SCRATCH COAT -
NOTICE TO APPLICANT:If.after making Mit Condo=of Exemption,you Mould 313 - ROOF NAIL
become subject to the Worker's Compensation provision,of On Labor Code,you must
7Z forthwith comply with such provisions nthis pannhthanxdenoted revoked. 501 - FINAL ELECTRICAL ENERGY
�C) CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
I Manby dErm that there in a consuvctinn lending agency for the performance of 503 - FINAL MECHANICAL ENERGY
x r�i the work for which this permit is issued(Sec.3011,Cie Cd
r] Ca LCnder'aNamc 504 - FINAL BUILDING ENERGY
Y Lender,Addrru
Z 505 - FINAL ELECTRICAL
;)t7 I ttnee that 1 haw rod his application and tura Mat Me show iinn
is 5 0 6 - GAS TES T
y
correct.1 agree to comply with all city and county ordinances and sum lawsws rcleting ng m /
OU building conswction,and hereby authnis mpresenmlves of this city to enter upon be - FIN PeI
N ,Move-memionnd properly for inspection purposes
(We)agree Io save,indemnify and keep harmless the City of Cupertino against 0 F IAL
ti Ilabilitieajudgments.costs and expense,which may In any way accrue against did City
in consequence of the graining of this permit. - A-7
APPLICANT UNDERSTANDS AND WILL COMPL('V ACL NON-POINT Issued by: 5 Date
14�
S URCE REGULATIO t `�
2 Re-roofs
S' store of ApidicaroConlactO \� Care6 2 OOF PLYWOOD NAIL
HAZARDOUS MATERIALS DISCLOSURE Type of Ro�f03 - ROOF BATTENS
Will the applicant or forum wilding occupant nam or handle hauNous material
Treed by the Curren..MdalelPal,Cede,Charr"r 9.12.and(M HOelth and Safety 604 - ROOF IN-PROGRESS
0 DYon v�ty�J Na
en zs25532a)? ,�g All roofs shall be inspected prior to any roofing material being installed.
Will the applicant Or fuluk building occupsnl use equipment Ordevicet which If a roof is installed without first,obtaining an inspection,I agree to remove
emit heundou it cooumitonts as defined by IM Bay Arta Air Quality Managemcm all new materials for inspection.
Mark,?
❑Yes No
I have read the MrsNtms mmarials subuchents under Chapter 6.95 ofdn,Califon
nice Heel Safety Code,Scccars 25505.25533 and 8534,1 understand that it the Wilding
data n -t'lly hew a tenant Mat it is my responsibility m notify the occurrent of the
m tai ^t5 which mtyyxmm prigrwissuancc brio Csnifca"of ry.
f-150.t•h 1 /A�S�Co-Sa Signature of Applicant Date
Owner or wadi irsd agent n," All roof coverings to be Class"B"or better