06030045 (2) CITY OF CUPERTINO "�aaz• d ,} pe+c `"`�'"' '" '''- *"�
BUILDING DIVISION PERMITILAL�.�sT(.T,Im 1 EORMATI�QN
BUILDING ADDRESS: MOHAMMAD SAMI P"'B"NO.06030045
18661 MEDICUS COURT
OWNER'S NAME: PERMIT ISSUE DATE
1 MOHAMMAD SAMI 6
E: SANITARY NO, CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG EIECr PLUMB MECH
I� l=
I96 LICENSED CONTRACTOR'S DECLARATION Job Description is
1 hemby aflrm Nn I am licensed under provisions of Chapter 9(ammcndnl
with Section IBM)o(Dlvan 3 of the Basimus and Pra(miva Gode.and my lice.is
+� inmBfamcand ffm HOUSE DEMOLITION
L1CenCpisv
Dow Y:-I•f OUl 'g UNIQUE CONSTRUWi4ED
A B/L #26104
CanUYlnr 'f
3
ARCHITECTS DECLARATION
l 1 understand my plans.hal he used u public retard$
U
ted� Licensed Professional
'N5
I hereby OWNER-BUILDER DECLARATION
7•s atTm that 1 am exempt from the Comraaor's License Law for the ��� /��
2
cog following meson.(Sada"7031.5.Business and Profession,Cade:Any city Of county - 1— 1006
3 9 which mOrmoa a fatal to construct,aiur.improve,demollsh.or¢pair any awcwm tI
_ic, prior to its issume,.mu requires the appliam farmers permit to file a signed stsuma,
that be 4 licensed former,m the provisions,of the C"nurcmrs lucme Law(Chapta9 Sq.Ft.Flo a VaIBaC 4386
p5 $ (commencing with Seeder 7000)of Division 3 of the Buainm and Profassiom Code)or
L g- that he 4 sump,dominate and the basis for the alleged camplion.Any violation of
Sadon 7031.5 by any applicant for a permit subjects the applicant to a dvd penahy of q}p7•,�y7 y�7j1 Occupancy y TyPe
not mom than lw hundred d"flan(M). 3 /
❑1,u owner offt pmpeaty,or my employees with wall as deo sale mnpauala",
will do Newark.and the muaure 4 notin¢Med oraacmd foraale(Sec.7044,Business Required Inspections
and Pmfealom Code:TM Contractor's License law don not apply to e an owner of q P
propertywho bu(Idamirnprews thereon,andwhodoessuchwerkhimaelf athmugh his
awnemployees,provldnd prowm alis mid
ore ns inendndoraRemd for axle r,
hawewn H dwd re orimprowrom,4told did arc Sear-hole Itothe owuer-
sed.j.r wIB haw the buNan of praying Nat he did at dIW a improv(or puryva of
ale.).
❑I.as away of the property,am eadnively senuaNng with Ocemed centrsemn m
cmuwn the project(See.7044.Business and Pmfe3dmu Cade:)The CatraaaYs U.
cele law does nos apply to an owner of property rile builds or improws ast eon,and,
who contracts for such projects with a conuacmr(s)licensed Puma.,to the Canuatofs '
License Law.
❑Ian eaemp, me, See BB PC fou ads moo th
0. /17"�-+'tea Dam �
RKER'S COMPENSATION DECLARXTIOit
I hereby affirm under penalty of perjury One of date fallewing declaamex .
❑(haw and w0l mainuinaCertilnmo(Coaa,toself•Wum fa warkefs Compo•
sado".a provided for by Section 3700 of it=labor Cade.for Ne Performance of de
work for which Nis permit 4 issued
❑I haw and will maintain Workers Compensation Imuran,u required by Seetia
3700 of the Jaber Code,for the performance of the work far which this permit 4Is ad.
My Workees Campematia Wurarnm artier and Policy number am:
Carrie: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
v
Meantime nd a,be cmnplc"If de permit 4 fescue hundred do0am(31o0)
or Ina)
I certify the,in the performance of the work for which this permit 4 issued.)shall net
employ any pemon In any manner an as to become subject to ge Waken'Compe�tia�
Laws of Calimmm.Darle p
Applies¢ U
NOTICE TO APPU As,3`.R•slmr robing this CeniOof
ae 'Esanption,you should
became subject m the Worke s Compemden p urnsimu of the labor Cade,you mus
,J Q foMwith comply with such prwrisims or this Namiuhall W deemed revoked.
,zr^ CONSTRUCTION LENDING AGENCY
E•+ IMreby atom Wt Nem 4ti
.examoa lending ageay forthe perfarmaeu of
fX 1
it.work for which this Permit 4 issued(Sex.3097,Civ.C.)
aQ Lendela Name
7 z Lenders Addma
fJ Q 1 cea0fy that I haw mad Oda application and sou that the above information 4
D. H cormcl.l alma to amply with all city and county aminase,and sum Ian rala,ing to
O U building construction,and hereby auborim repracnutim of this city to enmr open the
L27 .hove-mentioned property for inspection propos..
gy (We)agree to saw,indemnify and keep harmless the City of Cupertino against
r4 liabilides,judgments.cam and eapensea which may In any way utero against Said City
U Z in cengrenoe of she godamr;of this permit.
APPLICANT UNDERSTANDS 09 WILL COMPLY WITH ALL NON-POINT Issued by: Date S l2,tu
SO�RC,,EULATIONS. ( �ZIC
[Ah z mnuaa��—''or S Re-roofs
tgnatum of AppligC" Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicom Of future building aavpansaom orhandIc haardom mauriai
as deMcd by the Cupertino MunicipW-1,161al Code.Chapter 9.12.and the Halh and Safety
uc,sacihm 2553x.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building Occupant ase equipment m dedm which If 8 roof 1$installed without first obtaining an inspection,I agree t0 remove
emit haardaus air contaminants as delved by the Bay Ama Air Quality Management all new materials for inspection.
District?
❑Yes 4
I haw mad the hafamaa mauria4 requirements uncia Cbpur 6.95 of the Cali for-
me Health&SafayOods,Sections 2305,25533 and 25534.1 understand thatfNe building
does no,currently hew a u"am that It Is my mepomibilty m notify the oceupu,of the
requl n4wmhmustbeanpdrtoiausnaaceninaauofOcapancy. Signature of Applicant Date
�or authorised agent Dae All roof coverings to be Class"B"or better