04110175 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT VC GTORINFORMATIO AMY ,
BUILDINGADDRFSS: CARL FARSAI PERMrrN004110175
10106 CARMEN RD
OWNER'S NAME: PERMrr ISSUE DATE
CARL FARSAI 11 /30/2004
ONE: a SANITARY N0, CONTROL NO.
ARCHITEC(ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+�aOp LICENSED CONTRACTOR'S DECLARATION
i I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Descriptio(((� (� �y D
with Section]IXIU)of Division 3rrmc Business and Profusium Code,.arta my licenseis A��}�I��J''(d/��U
in fullfortcandeffeck UPGRADE ELECT. SERVICE (200
p n z License Class Lic.p
—p Dale, CSDECL DEC 2U�4
acter
ARCHITECTS DECLARATION
I understand my pts shall he used as public rtcmdv
JyU
d a S Licensed hereby ioral D
w OWNER-BUILDER DECLARATION
3 0 Y I hereby.(Sinn(Second
11. exempt from @c Contractors rs License Law for the
s O O which reg reams(Sccuot ]f10 1.5,Basi ter. and Professionm,or:Any oily or county
which its jam a permit re cumsthe,alley.intforsu h padonr itt or a pair any xtrunum 6
FZi Chior t he isl Tensed c.also pursuant
the thovisios;of for suchmon'sLRense Lawgned stat
mem
Nalmerccenwitpursuant 70th)of Division 3 the Common's and Professions
(C ode)or Sq.Ft. Floor Area Valuation
a. that hail ng p,Obersecuonal it the
Division)of theeged cessand ProfessvicCSNc7 or
i�$ Nn he u eaunpt Nucfrom and me bmu far me alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of g 0 Occupancy Type
not more than five hundred drllan($50)).
❑I,as ev ref of the property or my unplryres with wages As limit.1.compeasulon,
will do the work,and the structure is not intended or offered for safe(Sec.7044,Business
and Professions Code:The Contractor's License Law docs not apply to an owner of Required Inspections
property who builds or improves memo¢,and who deessuch work himself orNmugh his
own employees,provided mat such improsememu tic not intended oroRared foreale.If.
however.fee Wilding or improvement is sold within one year of completion.Ne owner.
builder will have the harden of proving that he did not build or improve for purpose of
sale).
1,as owner of the property,am exclusively commeting with licerro d contractors he
conmmet Ne project(Sec.7044,Business and Preferslom Cade:)The Contractor's Li.
cents Law dies not apply to an owner of property who Wilds or improve @)man,and
whostmmets for such projecerwilharadmi or(sI licensed pursuanuo0e Contraetnb
0hamand
,B&PCrrrthiareamn
Dale
Ri9Cenificate
A ON DEC RAT(
(/ f perjury roe of owing declarations:
ntaiof Consent to self-insurefor Worker's Compen-
sation,ss provided for by Senior 3100 of de,labor Cade,for me performance of the
wank for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance.As required by secure
37M of the tabor Cade.for the performance of the work for which this permit is issued.
My Workers ComPansation Insunn¢carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crdsaectimt recd not Wcantpined ifthe perm .!fret undreddrllars($100)
or less.) ,AJ
1 ccnify that imaac.pI reane memoir dh this ped a issued,1 shall not
employanype`, ar(nym norm m bjeelt h keri Cnmpemauon
laws of Ca,o b
Applicant
N CE APPLICA sIf,.per aking this Cempeam of Exemption,you should
!CO VCE
to the Worker's Compensation provisions of the tabor Cad),you mum
.,Z, form a comply with such provisions m this permit shall W deemed mvokcd.
Z O CONSTRUCTION LENDING AGENCY
P'; I hereby affirm deal there is a construction lending agency lm the Performance of
me work k fur which this per nit is issued(See.3097,Civ.C.)
f31 Iendm's Name
0. Landers Address
0 Z
U 0 1 certify the 1 have read this application and sum mat the AIR.informuium is
D.F correct 1 agree to comply with all city and county ordinances and some laws relating to
DU Wilding camwnion.and hereby aumame represommiass of this city in enter upon the
r W ahovomcrome d propeny for inspection purposes.
(Wr)agree to save,indemnify and keep harmless the City of Cupertino against
Liabilities.judgments.costs and expesu)s which may in toy way accrue,against said City
U in cornequenc)of the rare u(mis
^ APPLICANT STA ND LL CO LY WITH ALL NON-POINT Issued by: Date
SOURC T O
F ?� Re-roofs
TAP ran o mr s Data
AZ RIA!1D Type of Roof
Will me applicant ur fuwrt building occupant start or handle hazardous memriel
As defined by the Cupertino Municipal Coda Chapter 9.11,and the Hcalm and Safety
odea Schon zss3z(a)? All roofs shall be inspected prior to any roofing material being installed.
�Yu �No
Will me applicant or(marc building occupant use cquipmcnt or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit humorous air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes AN.
I have mad the hvard,ms aW4yss i��mod" underCW,um6195.ftheCmifm-
nuH a, bag553M 25534.Iunmalry nueXtri Wilding
drat no t n rimy re o 'hility m notify the occupant of the
req mem )h W rrroisstr cemrato roc 'ancy. Signature of Applicant Date
�'w�nrrJ Data TP J ( 3All roof coverings to be Class"B"or better
n