07060242 ---------------
CITY OF CUPERTINO QRMTI(»
BUILDING DIVISION FERMI
PERMIT NO.
BUIL l GflD1 aESS: ADVANCED D,EVELOPMENT/JACOB 07060242
ARATA WAY _ PERMIT ISSUE DATE
07/27/2007
OWNER'S NAME:
2933 BENJA MIN CT SANITARY NO. CONTROL NO-
JACOB SAIDIAN,NE: (408)(408) 891-1639
BUILDING PERMIT INFO
BLDG ELECT LUMB AMEH
�C J
ARCHITECT/ENGINEER:
0 ZO LICENSED CONTRACTOR'S DECLARATION
Job Description
V
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 70(10)of Division 3 of the Business and professions Code.and my license is HOUSE DEM(
=y in full force and effect. Lic tr
t2 Z License Class— Contractor
t-inDam ARCHITECTS DECLARATION
ay,a I understand my plans shall he used as public records
)0.0
w F' Licensed Professional
p< OWNER-BUILDER DECLARATION
I< i hcrchy affirm that 1 am exempt from the Contractor's License Law for the
p O following reason-(Sectio Q7cnnswcBusiness
improve.demolish. r repair anye:Any city or county
swcture Valuation
� which requires a perm licant for such permit to rile a signed statement Sq.Ft.Floor Area $5000
u=rA prior to its issuance,also requires the app
-?a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
e z C (commencing with Section 7000)of Division 3 of the Business and Professioviolation of ns Code)or Number Occupancy Type
u that he is exempt therefrom and the basismit sue alts ged the
applicant
p cpar°m a cin. v 1 penalty of
3751203
y Section 7031.5 by any applicant for a pe Jet
not more than five hundred dollars(5500)•
❑I,as owner of the property,or my employees with wages as their sole compensation, Required Inspections
will do the work and the.--is not intended or offered for sale(Sec.7044•Business
and Professions Code:The Contractor's License Law docs not apply to an owner of
propertughhis
y who buil provided that such improvements are not intended
fcOn and who does such work ho offered ulfor or sale if,
own employees,p
however,the building or improvement is sold within one Year of completion, a owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
1,as owner of the Property,am exclusively contracting with licensed contractors to
construct the project(Sec.71144.Business and property
whoProfessibuildns s of Ibetegn:)The Contractor'sand.
cense Law docs not apply to an owner of property pursuant to the Contractor's
who contracts for such projects with a contractor(s)licensed p
License Law. B&P C f this reason
0 I am exempt un er Sea
Date
Owner
ORKER'S COMPENSATION DECLARATION
.41r --by affirm under penalty of perjury One of the fallowing declarations:
0 I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work tar which this permit is issued. required by
Section
0 1 have and will maintain Worker's Compensation insurance,as req
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation insurance carrier and Policy number arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if thepermit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,l shall not
employ any person in any manner s to become subjc o t Wor tercnsation
Laws of California.Date
Applicant
ld
NOTICE TO APPL.►C hoo
:If,after making this Certificate of Exemption,you s
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
4 1 hereby affirm that there is a construction lending agency for the performance of
p4> the work for which this permit is issued(See.3097,Civ.C.)
(Ll Q Lender's Namc
.ateZ Lender's Address
1 certify that i have read this application and state that the above information is
U 0 correct.I agree to comply with all city and county ordinances and state laws relating 10
V. Ubuilding construction,and hereby authorise representatives of this city to toter upon the
above-mentioned property for inspection purposes.
h�+ CWi (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accmc against said City Date
in consequence of the granting of this permit.
U rz APPLICANT UN RSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b 1:
SOURCE RE ATiONS. Re-roof`.,
Date
aturc of Applicant/ContractorType of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
oof s shall be inspected prior to any roofing material being installed.
code,Section 25532(a)? All r
t
D Yes �No
If a roo�'is installed without first obtaining an inspection,I agree to remove
gement all new materials for inspection.
Will the applicant or future building occupant use equipment or devices which
emit hazardous air conta pants as defined by the Bay Area Air Quality Mona g
District? N0
0Yes LI
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nialicalth&SafetyCodc,Sections 25505,25533 and n34`�understandica ttv nfthe
i —_ Date
docs not currently have a tenan t it is issua�ccOf a Certificate of Oce ancy. SignatL re of Applicant
rcquireme which must tP Of All roof coverings to be Class"B"or better
Date
0 r authorized agent