07030097 -7-7777777--
CITYBUIOF CUPERTINO � 'T� �CTt?R�� RMAT��N•
LDNGIDIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS: TBD — r 10 BE DETERMINED 07030097
21800 RIFREDI CT
PERMIT ISSUE DATE
OWNER'S NAME:
HAMDAN FAYAD 13
SAN
/2007 ITARY NO..
CONTROL NO.
'NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
a 0 o a
p LICENSED CONTRACTOR'S DECLARATION Job Description
j u I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z 00)of Division 3 of the Business and Professi
ons Code,and my license is REMODE_-BEDROOM, BATH & LAUNDRY
with Section 70
>>y in full force and effect
License Class Lic.#
F
Contractor
wDatc
� ARCHITECTS DECLARATION
j a< 1 understand my plans shall he used as public records
)yrJ
u.H Licensed Professional
O a OWNER-BUILDER DECLARATION
az I hereby affirm that I am exempt from the Contractor's Liccnsc Law for the
p ta7 following reason.(Section 703 L5,Business and Professions Code:Any city or county
{i which requires a permit to construct,alter,improve,demolish,or repair any structure
y prior to its issuance,also requires the applicant for such permit to file a signed statement Sq,Ft.Floor Area Valuation
-?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $7000
i F (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or
L 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 of 35716120
q�1 Number
1
not more than five hundred dollars(5500).
❑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 for sale(Sec.7044.Business Required Inspections
and Professions Code:The Contractors 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 emplo provided that such improvements are not intended or offered for sale.If,
however,th uilding or improvement is sold within one year of completion,the owner-
builder ' 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-
Law does not apply to an o of properly who builds or improves thereon,and.
w4conmcch projects Ih contractor(s)licensed pursuant w the Contractor's
LiW. 8 tit P C f this anon
❑ der Sec Date 13 K 'S COMPENSATION DECLARATION
irm under penalty of perjury one of the following declarations: -
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 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 Workers Compensation Insurance carrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc hundred dollars($100)
or less.)
I certify that i e p ormance of the work for w 'h this permit is iss ,I shall not
employ any rsan' any ncr d as to he m bject to the Worker pcnsation
Laws of ifori .Da �—
Applic
NOTICE CA making this Cc.fGcatc of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
z C CONSTRUCTION LENDING AGENCY
[~ .. I hereby affirm that there is a construction lending agency for the performance of
fZ r7 the work for which this permit is issued(See.3097,Civ.C.)
W Q Lender's Name
z Lender's Address
U C) I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating to
n Ubuilding construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
t) liabiliues,jud merits,costs and expects hick may in any way accrue against said City
V Z in consequent f the granting of this it. Date
APPLICA UN STANDS A WILL COMPLY TH ALL NON-POINT Issued by:
S RCE G ATIO S.
- I$ 0 Re-roofs
tractor °arc Type of Roof
ARDOUS MATERIALS DISCLOSURE yP
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Munrc' al Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All ro ifs shall be inspected prior to any roofing material being installed.
❑Yes Nn If a rcof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future buil ' g occupant use equipment or devices which
emit hazardous air contaminants as mcd by the Bay Arca Air Quality Management all new V materials for inspection.
District?
❑Yes Nu
1 have read the hazardous mate' requirements under Chapter 6.95 of the Califor-
nia Health&Safct ,Sections 2 25533 and 25534.1 understand that if the building
docs not torte have a tenan t' is my responsihil' to notify the occupant of the Date
requircmc hi ust be r to issuance ora enificate or Oce ancy Signa.ure of Applicant
All roof coverings to be Class"B"or better
Owner r au o'zc a are