04100086 (4) F,43
OF CUPERTINO `
ILDING DIVISION PERMIT CONTRACT OR INFORMATION.-;�
BUILDINGADDRESS BROKER PERMIT NO410 0
KIM ST
NAME: - PERMIT ISSUE DATE
Aft ABOLLAZL KHOSROWHOYGI 2385 LINCOLN AVE 10/13/2004
IV NE: SANITARY NO. CONTROL NO.
(800) 639-4527
ARCH TECT/ENGINEER: BUILDING PERMIT INFO
BLDG 0 ff PLUMB MECH 0 0 0
vOo LICENSED CONItdCfOR'S ;?[Ln RATION
F 1 nonny arum mm 1 am licensed ane=r p ff s of Chapter v(cnmmcnting lob Description
_?G wilegrakinn]IIJMpceDivisiun]of iM1C Busine ri;lrcaai��n.erada.and mylicen:r is WINDOW REPLACEMENT
Integra acrccn. 3
p nz Li Lie.a
Z�, DateContra
/�)J ARCHITECTS Doj
ECLAI N
,i`d< 1laoJ my plans shM all used vs public records
Dit dU
"y Licensed Professional
OWNER-BUILDER DECLARATION f'
a y 1 hereby affirm that I um exempt from the Contractors License Law for the /
p O following reason.(Sterna 7031,5,Business and Professions Code:Any city or county
lam which requires a permit to construct,almC improve,demolish,m repair any structure $7726
't—'^ poor to its issuance.also requires the applicant for such Permit to rile a signed statement
�R' that he is lireaed pursuant or the previsions it[the Contractors License uat
Law(Chapter9 Sq. Ft. Floor Area / Vail.;
,4l-$ (cam me sting wi th Section Was))of Division 3 of the B dilator and Professions Code)or
oo`<— that he is exempt therefrom and ft bun for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit aubjcets the applicant to a civil penalty of
not more man five hundred dollars(Sim). be �j�9crcupancy Type
❑ I.as owner or the property,or my employees with wages as thchoore compensation,
will do me work.and the structure is not imcnded of offered for sale(Sec.201,1.Business
and Profession Code:The Contractor's Licease Law does not apply to an owner or Required Inspections
property who builds or improver thefcon,and who dues such work himself or through his
own employees,provided that such improvements are not intended or offered for sant.If, -
however.line building or improvement is sold within one year of com fiction.the owner-
builder will have the burden of proving that be did not build or improve for purpose or
sale.).
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to
consumer the pmject(Sec.2014,Business and Professions Code:)The Contractor's U
nu taw doer not apply to an owner of pntpcoy who builds or improvs,Water.and,
who contracts for such projects with a contracam(s)licensed pursuant to the Contractor's
License Law, e
❑ l am exempt under See. ,B&P C for this reason
Owner Date
WORKER'S COMPENSUION DP-CLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 bare and will maintain a Ceoifieam or Consent m sel6insum for Worker'acompen-
satim,as provided for by Section 32m of the Labor ewe,for the performance of the
ark for which this permit is issued.
ED 1 have and will maintain Worker's Compensation Insurance,as required by Section
37W of the Labor Code,for the performance of the work for which this permit is issued.
My Worker'sCnifensaiion Insu u,{aria and Poli= umbkrare:
Fr's. Poli 151 F33t'� .
CERTIFICATE OF EXEMPTION M WORKERS'
COMPENSATION INSURANCE
(This section need not t e completed if the permit is far one hundred dollars{S100)
Its")
I certify mat in the performance of the work for which this permit is issued.I shall nor
employ any person in any manner to as m become subject o the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccnilicare of Exemption,you should
become subject to the Worker Compensation provisions of the Labor Cole,you must
z forthwith comply with such provisions or this permit shall he deemed revoked.
'Z O CONSTRUCTION LENDING AGENCY
[ Ihereby affirm that there is a contrunlon lending agency l or the Performance of
nethe work for which this permit is issued(Sec.3W7,Civ.C.)
.Q Q Lendcr's Name
y lender's Address
C.)Q 1 coolly that I have read this application and sure that the above information is —
�F correct.I agree to comply with all city and county ordi nanms and sure laws relating to
QU building construction,and hereby summon representatives of this ei ty to enter upon[he
a ahoy(W mentioned e propmy for inspection keep ca. /
(We)agree to save,indemnify and which
harmless the Cityway sector
to Criteria.against
UN inconacsucance of the
grstsand expenses which may in any wayaccroc against said city
^ anfing or this Permit.
APPLICANT UNDF.RST DS�AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SO CGU ONS.
st
_ 1310LI Re-roofs
Signature of ApplicambConuacler Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future budding occupant store,or handle havmJous material
as donned by the Cupertimo Municipal Code.Chapter 9.12,and the Health and Safety
Cmlc,Section 25512(ap
�Ycs .:.!' All roofs shall be inspected prior to any roofing material being installed.
you
Will the applicanwr lotion,building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
IhaWrdous aircnmemloants as Jcfncd by the Bay Arca Air Quality Management all new materials for inspection.
Dtstrict?
❑Yes Lu
I have read me huvaNnus mamrials reyuiremems under Chapmr flus of lie Califfer.
hie Ha W&Safely Cmk,SeNum 25505.25533 and 25534.1 dnderamad Nat if the Building
does not currently haw a mnam,that it is my responsioloy In notify the occupant of the
require cwhicanuuhcm Llaim ktarseuvree or.C&4cidacidfC"rpermy
Signature of Applicant Dale
Or 0,yel —Oe,
_Ovorlih oramhunued agrnt Dam All roof coverings to be Class "B"or better