05020133 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT yCON TRACTQR�INFRMATIO, N
BUILDING ADDRESS: STARBURST CONST CO 111111100 5020133
21895 RATC)N PT.
OWNER'S NAME: PERMrf LgUE DATE
KHESIN
E:
SANITARY C OL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O O
fop LICENSED CONTRACTOR'S DECLARATION Job Descrip[ �� /\ ��®
V 1 Waby affirm that I am limnutl under provisions nrC ode, 9 fmmmensi is �s111
with Section 70rgB of Divixion]of Ne Bmimss and Prufrssium Codc,and my license is
j�2a Limn Ceand errma REMODEL/ADD ONE BEDROOM
i rose Clssx Lk.N
;�:�Ms. Commcwr FILLING THE 2ND FLOOR
£E ARCHITECTS DECLARATION �oo[
C 1 understand my plans shall he used as public¢courts tU{ J
JyU
u.G Licensed encs affix ®�
OWNER-BUILDER DECLARATION e
.�0 0 I hereby affirm Nm 1 ML.exempt from d r Cssion.o License law for the
KO O which ac reason.Permian ID]L5,Business and we,de mu Code:Any city os county
m whim requires a permit re uirmwet.alun improve,demolish. fie pair any structure
prior¢its ceased Formu requires sW applicant of for such pcumiuoicense Law(Chapter
(her he circinmcdpurstion7 the provisions of the Commaur'and Ponflaw(ChaparY Sq. FL Floor Area Valga[ 00
y�0 (cat he is exempt Section and)du Division]of NC egad m epi on.Miamcade)ar
i�$ Nat he u exempt thrtfrom and the buts Tor dM alleged cumptim.My violation of
Section 7031.3 by any applicant for a Permit subjects the applicantw a civil penalty of APN Number Occupancy Type
not mom Nan Bvc hundred dollars(SSW).
01.uownuofihe Pmprsty,or mY cmploycrs with wegexaz the'v sole compensation, 32619137 . 00
will do the work.and Ne awctum is not intended or offered for sale(Sec.LNa,Business
and Pmruslons Code:The Contractors License Law docs not apply in an owner of Required Inspections
property who builds or improves thereon,and who dommuchwarkhimself or through his
awn employers,provided that such improvements am not trained oro@rad forsale.IL
however,the Wilding or improvement is said within am year of completion,dra owner-
builder will have the Wrden or proving that he did not Wild or improve for purpose of
Gale.).
❑1.as owner of Ne pmpeny,am exclusive contracting with licensed commuters to
construct the project(Sec.?Bba,Busineis a d Professions Cudc:)The Conrxeries Li
cede law dors not apply to an o4.r �ny who its or improves thereon,and
whoconmatxfmmucbprojec w (sllic sedmivanuotheConuserohLicense law.
❑1 am exempt u .B&P fa tyis MasonJ 11w_Owner DateWORKER'SCN DECLARATION
I-mbYu(Rn iunderpenone of the ri llo ving declarations:
I ha. of will maintain a Crnihcme of Consenuo self-insum for Workers Comprm
ration,as provided for by Section 3700 of the labor Code,for Ne performance of the
work for which Nis permit is issucd.
❑1 have and will maintain Workcfs Compnwtion Insurance.as required by Section
37W of the labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance eanier and Policy number aa:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSUR NCE
(Thu section need natWcompleMJi he Pe it is froom dred dollars(5100)
or less.
1 celdry Not in the perfoumanec oft f ich Ni rmit is issucd,I sM1ail nos
employ any person in any r azw mom subjr oNC Workers'Compcnsation
Laws of California,D
App li rat
NOTICE TO APPLICA :If r making rs c 'fico¢of Exemption,you momW
become subject to the Worker;Com Pcnsatin vis m of the Lahm Cmlc,you must
.J O forthwith comply with such pmvisinru or shall be deemed revoked.
z C) CONSIAUCTIO ENDING AGENCY
(. 1 hereby affirm Nat there is a construction lending agency for the performance or
C 7 the work for which this permit is issued(Sec.309],Co.C.)
tai Lender's Name
11 Lcadcrs Address
M Z
U Q 1 certify that I have read this application and sure that the above information is
ty correct.1 agree to comply with all city and county ordinances and sus laws relating to
0 U buildingconeuuction,andhcrebyar uiartprrxnusivesofthiscitywemerupnnum
Y' D.1 glove-mentioned property for ins Un purposes.
F gy
We)agree to save,indent Ify nd keep ham less the City of Cupertino against
p3 liabilities,judgments,costs and pe a which may in maccrue y way acee against said City
U Z in consequence of Ne gr n f Ni Permit.
^ APPLICANT UNDE A S A D WILL COMPLY WITH NON-POINT Issued by: Date
S U N
Re-roofs
signuumof Appmaaucon or Data
HAZARD S MATERIALS DISCLOSURE Type of Roof
Will thcapphemilmfm building mermaid more or handle haaardms material
az ms.od by Nc Cupertino M it al Coda Chapar 9.11,and tW Hc.l M1 and Safcty
Code,Section 23532(q?
py. No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or rutura builfng occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
n mi,adous air conuminanu as nncd by dm Bay Asa Air Quality Management all new materials for Inspection.
Di trio?
❑Yes /
Ihovereadth ave sus redalsmquimmcnuundcrC pmr6.95ef Nc Celifoc
iia FiaslN&Safety do 505.25531 am125534.1 undersand thuifthc Wilding
does oat ha tm at it u my responsibility m notify the occupant of the
m ich t ourtoimaanmafaCrNhea¢of cep ry. Signature of Applicant Date
Uw U
nnararmad edagmt Daw All roof coverings to be Class "B"or better
C