03010011 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT i O,NTRACT0R-1NF0RMATION
BU I LDING A DURESS: WATER SYSTEMS PLUMBING PERMITS°.
10166 MC LAREN PL 03010011
OWNER'S NAME: 3844 HEPPNER LN APPLICATION SUB DATE
HATAMI MOHAMMAD H AND SUSAN 01/03/2003
]ONE: (408) 266-8222 SANITARY NO. CONTROL NO,
ARCH TECT/ENGINCER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
wwO, O O
�00 LICENSED CONTRACTOR'S DECLARATION Job DCSCT t7Y
1"i 1 hereby.from that 1 am licensed under provisions of Chapter Y(commencing
wAL
ith Section 7ufxq of Division 3 of theB ass anJProfcssinns Cid upJmylicenmis
ZO�a refers, clfecl,�'�/ .6� ?55 ` REPLACE MAIN WATER LINE. JARp 9 2003
License V la.x
Dam �� p'� Contructpr fµ}� Y ' S t t+3 _
ARCfIITE LARATION
-+ I understand my plans shall be u. public rncnrds
u BUILDING
H4C� Licensed Professional
OWNER-BUILDER DECLARATION
I hereby
affvm that 1 am exempt from the Contractors License Law for the
00 following reason.(Section 7031.5.Business and Professions Code:Any city or county
e' $ which requires a permit nt construct,alter,improve,demole lb,or repair any structure
w pnor mils issuance.also myui.theapplicmd kn,uch permit to lDe a signed statement
that he is licensed pursuant to to provisions of the Contractors License Law(Chapter 9 Sy. Ft. Floor Area $1YOGatlon
CF° (commencing with Sectinn 7(M)of Divisiao Sof the Busintra and Professions Cord.)or
i re3$ that he is exempt thertGom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit ubjects the applicant to a civil penally of Occupancy Type
not more than Eve hundred dollars($500).
❑ I,asowner order properly,army employees with wages as their sole compensation,
will do the work,and the structure is not intended oroffered for sale(Sec.7(WBusinesspyy4�
and Pmfessiotn Code:no Contractor's License raw does not apply to an owner of 202 - UNDERMIERF GKe UlYl7Y G
Property who buildsm improves thereon,and who doessuch work himselfor through his
own employee,provided that such improvements am not intended or offered for We.IL 301 — ROUGH PLUMBING
however the building or improvement is said within be year of complete..,the owner.
builder will have the burden of proving Nat be did not build or improve for purpose of 302 - TUB & OR SHOWER
sale) 502 FINAL PLUMBING ENERGY
❑ I,as owner of the property,am exclusively contracting with licensed contractors m 506 - GAS TEST
construct Ne project(Sec.7(14,Business and Professions Code:)The Contractors Li
cense Law does not apply to an owner of property who bunds or improves themon,and 507 — FINAL PLUMBING
who contracts for such p rjecls with a conuncmr(s)licensed pursuant o the Contractor's
License Law.
❑1 am exempt under Sec. .B&P C for this maxim
Owner Dale
WORKER'S COMPENSATION DECLARATION 1
I hemby affirm unJer penalty of perjury one of the following Jalantions:
❑ Ihave and will maintsinaCenifcem of Consent o self-insurt for Workers Compere
moon,as provided for by Section 3700 of the labor Code,for the performance of rhe
work for which Nis permit is issued.
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
371X)of the Labor Code,for the Performance of the work for which hots permit is issued.
M Worker'asCattyrtns him lnsunnce carver and Policynumh e.-
C y icr.S-Tl i1lT FN+1n,Policy No. 6—,;60
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be manphred if IM1e furnit is forone hundred dollars oI00)
or less.)
1 certify that in the perhmrmnee of Ne work for which this permit is issued,1 shall not
employ any person in any manner so as m become subject to the WorkersCompensation
laws of Cal ifomis.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Ccei ream of Exemption,you should
become subject to the Worker's Compensation provisions of the laMn Cade,you must
O z forthwith comply with suc h provisions or this Permit shall he deemed revoked.
O CONSTRUCTION LENDING AGENCY
iN+ I hereby alarm that there is a construction lending agency lea the performanccor
D: 9 Ne work for which this permit is issued(See.3197.Civ.C.)
W� Lender's Name
r7 z Lenders Address
J 0 1 certify that 1 have mad this application and sum that Ne above information is
f' conca.I agree to comply with all city and county ordinances and state laws relating It,
DU building construction,and hereby suthnsic rciosentativcs of not city to enter upon the
W above-mentioned property for inspection purposes.
Or (We)agree to sun,indemnify and keep harmless the City of Cupertino against
h Nabi lilies,judgments,costs and ape nseswhicIt may in any wayaccruc against said City
U z in consequence of the jimadin ofthis permit.
'—' APPLICANT U T DS AN ILL COMPLY WITU AL POINT Issued by: Date /A/Z;
SOU CER
03 Re-roofs
S' .lure plc t ran r Dote-
HAZARDOUS MATE 1 .S DISCLOSURE Type of Roof
Will the applicant or future huilJin6t cupur,store or handle hamsJous material
as Jefined M1y Nc Cupeniw Mu icipal Cswle.Chapter 9.13,and the Health and Safety
Gxlc,pYcs 25533(a)7 No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant n rotor building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Front haeardnux air cntri'm nk;as defend by the Bay Area Air Quality Management all new materials for inspection.
Doric, t�N�
❑Yes ❑
I have mail the arJws materia yuimmenu under Chapmrfi YSafNeCalifor-
1
A
lN& a Cr ,SntiNs2 533and2551JtmJersunJ 'f Ne holding
ese In a moa at i s my responsibility m notify the t of Ne
abemetpd lois crife.m.fa p Signature of Applicant Date
nraN ari.edagent Date All roof coverings to be Class"B" or better