01090076 (2):l1
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CITYSIIONNOPERMIT
BUILDING DIIVIIS
CONTRACTOR INFORMATION:
BUILDING ADDRESS:
PERMIT NO.
1548 PRIMROSE WY
01090076
OWNER'S NAME:
APPLICATION SUB DATE
M.M. KHORASHADI
09/19/2001
PHONE:
SANITARY NO. CONTROL NO.
Z ARCIIITECT/ENGINEER:
O
BUILDING PERMIT INFO
L
BLDG ELECT PLUMB
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby vfOrtn mat I am licensed node, provisions of Chapter 9 (commencing
wwith Section 7")ofDivision3oftheBusiness and I'mmssionsCode. and mylicense
REPLACE FUNGIS DAMAGE &
Lian lI`°rc`"° `B `t' uc.._at'r , q Cl a)
HALL BATH TUBBACK.
Dam I Contractor
1 CHf1ECf'S�C A2 ONa
1 m plans rho
O cd rofes.vi nal
i OWNER-BUILDER'C TION
I hcmby affirm that I am exempt fm c Conuecmr's License law forrhe
following mason. (Section 7031.5, Business atW Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any swcmre
a.prionoiucensed e,eluantto ms thevisions
of the Contranrtiuo LicenseLa (Clia,peem�--
- mat he itcial, licensed Sectintry t(Kpof Divi,i a theC Basinrx; mal Pr Lawcna, Cnr9
or Code)
BupinessarNami,
is $ennchroma dthe
), 3 S F,t: FlOOC At'ea.s
�(,l,l„w,t Y,,;, ', 01;
UallOn
bails
(c thathe the Any
or that he is exempt m<rcfmm and the basis for the elldge0 exemVtion. Any violation
exam
1 ..}Is, G.'�:, Jd.1•y:�,t
of Section ]031.5 by any applicant for a permit subjects me appliant m a civil penalty
nr not mate m.n five nnnarea dpnata ($s(a).
umber
� � � Occupancy Type
❑ I, ax awncr °f the propcnY• ur mY employees with wages az reel, sole compensation.
will do the work: and mwr
e sam is not intended or .Head for sale (Sec. 7614,
Business and•Professi°ns Code: The Contractors Limns Law does not apply m an
a.,:
202 - UNDERFLU0 it �lVLVG '
owHer of property Who builds or improves mcreon. and who does such work himself
orhis own employees. Provided dot such impruvetrcnu are ria intended or
-
301 - ROUGH PLUMBING
offered for sale. IL however, the Wilding or improvement is sold within enc year of
302 - TUB & OR SHOWER - -
completion, the ownef-builder will have the burden of proving that he did not build or
improve forpurpmeofsale.).
502 - FINAL PLUMBING ENERGY
licensed
O1,uaowner ofthe p(See
506 - GAS TEST •' `---
7,.nt Business dPorfitssion, Cmilronto
haccom t the Dr sea (See to a Business dna Rot Ions Cade:) The Convanm's
ems law does ria apply man owner of property who wiles improves
i
507 - FINAL PLUMBING . • ..
tfficarion.the
s
and who contracts for such projmu. with a ronpactods7 licensed purwam to the
J -
01Contour,....axeLicense law.
❑ I am exempt under Sec. . B@ P C for this reason
Own Data
,
WORKER'S COMPENSATION DECLARATION
9 A L E
1 hereby ofOnn under penalty of perjury one of the following tleelaratlons:
° 1 have and will maintain a ceeificaie of Consrnt to msafdmum fm Wmkn'a
h
Copensation„as for by Sanson 37W of rhe labs, Code, for re
L
OCT •I 1 O qoo1
provided
7. 'perfommnce cf the work for which this Permit is issued.
° 1 have and will maintain Worker's Comprnsauon Insurance, as required by Section
3700 of the IaMr Code, for the performance of the work fm which this permit is
BUILDING
issued My Compensation Insurance &arier•and Policy number am::
_
CWorker's'
? LJG l 82
•c,di' L£61a/O+ INOFEXE
( s:!''i 1 :Z 1 '4, i r t'3'I :,. ” „u,..
M KERS's
1 :CERTIFICATION OF FROM WORKERS?
t
ATION LION
COMPENSATION INSURANCE •: '_,
-_-�__,. _. ...._.. ._-
(This rection n¢d tins be completed if the permit is fm case hundred dollars
•' I' i ' �'
($1000 or less.)
. omit is issued, I
i Iempl Uaiinthe .inpynor which thispe
.. .. ...._ .. .., - _........
•, Ill” ;I;-�
a to askfbe
shall not employ any limon in any munnen so as to'become subject m he Works,.'
Compensation law:: of Cmifdmia: Dam
Applicant .. ,.
- .. ... ._
Exemption, youshould
NOTICE TO APPLICANT If, after making suisovisios
oar
the Compensation
become subjectcomply per all belabor Cade. you must
this
� forthwith 2omply wim such provisions or this parent shall be dcemW revoked.
such
�
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7 " CONSTRUCTION LENDING AGENCY
1hcrtby affirm mat them is a construction leading agency for e performance
of Nd wvrk for which his permit is issued ISm. 309]. Civ. C.)
�
..
� Lender's Name
Lender's Address"
I certify mat I have mad this application and sure that be above information is
•'den: I .gree a comply with all city and county ordinances and state laws relating
to building construction. and hereby authorize representatives ofthis city to enter upon
Q the abuse-memkined property far inspersion purposes. � ,
W (we) ogme m nave, indemnify and keep harmless the City of Cupertino against
0 liabilities, judgments, costs and expenses which may in any way accrue against said
C the gamingof suis pmnit.
SANDWIL MP RHALLNON 1
Issued by: Date
M
enn mem a
Re -roofs
"HAZARDOUS ATERIALS DI URE
was ire ppficnm t r t wilding «cepa t n haeme haisrJnus mama l .
- Type of Roof ... . .
aztlefatl byre Cupenv M 'W�CaI Ch 9.13. mdthe Heals, and Safety
- S \ ,
..'I' 1.f..:
Cade$ a Z5J2(.) k( .. yy, ,t
I
t:�.
. as-All❑v'AV`"°.
- roofs shall,be Inspected prior to any -roofing material being installed.
Will the applicammf.m Wilding occupant uxequipmetn ordevices which
If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous an contaminants as defined by he Bay Area Air Quality Management
liamen
all new materials for inspection. Applicant understands and will comply,with
°Yes ; " -
all non -point source regulations.
it _
:.niaHealth the materials 505. men, under Chapter 6.95 of me
Cada Sections 25505 and 25534,1 understand that
California lama Heals, Safety Code.
, t it
- if the building does tlhich tenant, that is myresponsibilitymnoufy the
_
as
m
cc�s which mm et Pas irxuance of a Cmif¢ate f
Signature of Applicant Date
v, 9 0 /
roof coverings to be Class "B" of better
D.
or.mhvrize agcm ' Dat
1All
OFFICE