07010125 CITE'OF CUPERTINO
BUILDING DIVISION PERMIT
+ � R GTQR Il ?RM�TI(IN';
PERMIT NO.
BUILDING ADDRESS:
10411 BEARDON DR MANSOUR KAVIANPOUR 07010125
PERMIT ISSUE DATE
r'"""GR'S NAME:
AANSOUR KAVIANPOUR 10411 B:�',ARD
SAMTARY NO. CONTROL NO.
PHONE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
i
00 LICENSED CONTRACTOR'S DECLARATION Job Description
v I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z with Section 7000)of Division 3 of the Business and Professions Code,and my license is DEMO S F:AWL
r<o. in full force and effect
j z License Class Lica ALI ' S CONSTRUCTION PAID BL 1/16/06
t- pato Contractor
ARCHITECTS DECLARATION
i a< I understand my plans shall be used as public records
)yU
o y Licensed Professianal
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
p OoG following mason.(Section 703 1.5,Business and Professions Code:Any city or county
c la. which requires a permit to construct,alter,improve,demolish,or repair any structure
"(0' prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
-Z, Ft.Floor Area
- a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 ��Q
_ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $10000
i that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of32630126
APN Number
not more than five hundred dollars(5500).
Q I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered Corsale(Sec.7(M4,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an Owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the 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.7044,Business and Professions Code:)The Contractor's Li-
cense Law docs not apply to an owner of propert o builds or improves thereon,and,
who contracts for such projects with a co icensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B&P C Iar thio!coon
,r Date
Wf� TION DECLARATION -
I hereby aff)rrb= a enalty of perjury one of the following declarations:
❑I have and will ntam 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 for which this permit is issued.
I have and will maintain Worker's Compensation Insurance.as required by Section
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 the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as w1ccrtme.3diccl to V Workcrs'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
tom. 1 hereby affirm that there is a construction lending agency for the performance of
ai> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is
uU 1- correct.I agree to comply with all city and county ordinances and state laws relating to
(DUbuilding construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City f�
V Z in consequence of the granting of this permi Date
►- APPLICANT UNDERSTANDS AND. MPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicanU o Date Type of RoofHA
. AA
RDMATERIALS DISCLOSURE yP
Will the applklfit or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
1c,Section 25532(a)? / All roofs shall be inspected prior to any roofing material being installed.
p Yes 2<0
If a roof s installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
Cl Yes Qj Nd
1 have read the hazardous mate' quiremems under Chapter 6.95 of the Califor-
nia Hcalth&Safcty Code, ons .25533 and 25534.I understand that if the building
docs not currently ha na at it is my responsibility to notify the occupant of the
rcquircmcnts ust t e of a Ccrtificatc occ pancy. Signaturc of Applicant Date
All roof coverings to be Class 'B or better
gent oto