05010046 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT r,CONTRAGTOR INFORMATION
9.rty.. .Alrvuta h,.f
ILDING App 5_p PERMIT HOO 5010046
9U 70"LORES AVE
-NCR's NAME: PERMIT LSSUE DATE
HAMID & MANDANA SOLEIMANI 01/07/2005
ONE: SANITARY N0, CONTROL NO.
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
_J 0 0
I0, LICENSED CONTRACT'OR'S DECLARATION `n
�d 51 hereby affirm that 1 am licensed out,provisions of Chapter 9(commencing .Iob,Desi Ilpti n
_zw with Section 70(0)of Division 3 of the Business and Profession.,Codc,and my license is 4/
IZ<n inmBforcendeffect. REPAIR GARAGE y '%
License Class Lic.Is
QF p Date Contract. ,
ti
f to u I understand my pl nsshal M used s public meord /^'
2l
u G Licensed Professional
`OS OWNER BUILDER DECLARATION r /,
2<F1 hemhy affirm that 1 oro exempt from the Comraaofs License Law far the 7
p o following reason.(Section 703 1.5,Business and Professions Code:Any city Or county' �,' ' 'l,
m which requires a Permit to construct,alter,improvedemolish.or repair any structure rO O O O
prior m its issuance.also requireuhe applicant for such remit rile a signed statement
E< thatheislicensedpursuanuothepmvisionsoftheComracturiLicenseLaw(ChapterY Sq.Ft. Floor Area "JJ .:' Valuation
R!: (commencing with Section 711007 of Division 3 o(the Business and Profesinna ewe)or
:3 that he is exempt❑omfrom and the basis far the alleged exemption.Any violation of
Section 7131.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 WPN+Q13)Ber0 0 Occupancy Type
not morethnerchundredunBan(S5Bu). P Y YP
❑I,as owner of the property,or my employees with wages as their mile compensation,
will do the work,and the shuctute is not intended or offend for sale(Sec.70,14.Business
and Professiom Code:The Cpnmctofs License Law docs net apply}u in owner of Required Inspections
progeny who builds or improves Orman.and who does such work himseff or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is old within one year of completion.the owner-
builder will have the burden of proving that he did not build or improve for purpose of
mt '
1.as r of Ne property,am exclusively conmming with licensed contractors m
c smct theepmjea(Sec.704A,Ousinca'anO lsrolcssinns CodcU The ConOanori Li
come Taw docs not apply to in owner of property who Wilds or improve thereon,nd
who comncts for such projects with a conmclofls)licensed pursuant to the Contractor's r
c Law.
am exempt under Se .B&P C for this reason
O c Dal
O K R'S COMP 10 ECLA
I hereby afrom under penalty of perjury one of the ridlowmg declarations:
1 have and will maintain a Cenif?ate of Camem to self-insum for Worker sCompcn-
sation,as provided for by Section 3700 of the Labor Code,for the perfoona«e of the
work for which this perms is issued.
❑Hove and will maintain Workers Compensation Insurance,as nyuirtd by Section
3700 of the Labor Cade,for the performance ofrhe work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number aa:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need in,Wcompleted if the permit is forone hundred dollars(SIN))
or les,)
1 certify that in the perfnmmme of the work for which this permit is iswcd,10.11 nut -
employ any person in any manner so as to become subject to ft Workces Compensation
Laws of California.Da¢
Applicant
NOTICE TO APPLICANT:Ir.after making this Cmifcate of Exemption,you should
become subject to the Workers Compensation previsions of the Labor ad[,you must
D Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z'O CONSTRUCTION LENDING AGENCY
1 bemhy affirm that time is a construction lending agency for the performance of
5 the work for which this permit is issued(Sec.3NG,Co,C.)
1] Lender's Name
Lender's Address
7 2
;j Q 1 certify that I have mad this application and sure that the above informatiun is
1. F^ correct.I agree to comply with all city and county ordinances and sure laws relating to
Z)U building construction,and hereby authorize representatives of Nis city to enter upon the
abovomentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupenino against
I, habilitlea j odgments,costs and ex pensee which may in any way accrue against said Ci ty
J Z in consequence of thegrantingof this Permit.
..
APPLICANT UNDERSTANDS AND WILL MPLY WITH ALL NON-POINT Issued by: Date `� \✓
tSOUREGULATIO 5. Re-roofs
o ppmany ontnctor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
ll the applicant or future building Occupant store or handle haruduus material
by the Cupenino MunicipalCode.Chapter 9.12,and the Health and Safety
ion]5533(x)? yr{ All roofs shall be ins ected rlor to an roofin material beinYea P P Y g g installed.
dl thea licantor fuwrc builJin «eta ant use a If a roof is installed without first obtaining an inspection,I a ree to removepp g p quipmnt or devices which gdnus air conuminenu as dcfncd by the Bay Arca Air Quality Management all new materials for inspection.
' /
❑Yci PVI pIQ
I have mad the haraNnus materials requirements under Chapter 6.95 of the Califor-
iia Health&Safety Code,Sections 25505.25533 and 255 M.1 uWksmOd thus if the Wilding
doe not currently hoc a roan,thatit u 37, neapons I mrytM
nW .opnssur Ne
onionemn.whiehm the ma nor to name or.cern eency. Signature of Applicant Date
k 1%_L (epz All Too(coverings to be Class "B"or better
cr or au o d agcm Dat?