07020128 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDJN� QLjDjLESBEARDON DR TBD - TO 3E DETERMINED 07020128
BUILD[
�J L�l 1 PERMIT ISSUE DATE
OWNER'S NAME:
MANSOUR KAVIANPOUR 05/11/2007
SANITARY NO. CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITECIENGINEER: SFDWL-2 SPORY 3, 437 SQ
BLDG ELECT PLUMB MECH
FT/GARAE3E 5±8 __S
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IWp LICENSED CONTRACTOR'S DECLARATION p escdptlon
r_ I hereby affirm that I am licensed under provisions of Chapter 9(commencing
U _=7
Uwith Section 7000)of Division 3 of the Business and Professions Code,and my license is
"0 y in full force and effect.
v�Z License Class Lic.#
F- Dare Contractor
.a ARCHITECTS DECLARATION
a< I understand my plans shall be used as public records
)W U
e w i- Licensed Professional
O a OWNER-BUILDER DECLARATION
�n I hereby affirm that I am exempt from the Contractor's License Law for the
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p O following reason.(Section 703 1.5,Business and Professions Calc:Any city or county
9 which requires a permit to construct,alter,improve,demolish,or repair any structure
Z yprior to its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.11.Floor Area Valuation
YF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i
5 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of AI IN Number Occupancy Type
not more than rive 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 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
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Cade:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑I am exempt under Sec. /� B tit P C for this ream
Owner �`�• 441-',,2
Due
WORKF�'COMPEN ;'IAS ON DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workces 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 Workers 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 are:
Carrier. Policy No.:
CERTIFICATE OF EXEMYnON 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.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.D e
Applicant itA/
NOTICE TO APPLICANT:If,after makin this Ccrtiticatc of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
Z V) CONSTRUCTION LENDING AGENCY
(-t.�� I hereby affirm that there is a construction lending agency for the performance of
IY, the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Lenders Address
U O 1 certify that I have read this application and slate that the above information is
LI, ►- correct.I agree to comply with all city and county ordinances and state laws relating to
rJ U building 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
ti+ t) liabilities,judgments,costs and expenses which may in any way accrue against said City
U z in consequence of the granting of this permit.
�-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: S Date r
SOURCE REGULATIONS,
11-07 Re-roofs
s gnatuurc oof A p tcant/Contractor I Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes B'No
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? ��t,v
El Yes `il W
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which m be mettWrior to issuance of a Certificate of Occupancy. Signature Of Applicant Date
ACI IA02-A 4.1— It-615,7 All roof coverings to be Class "B"or better
Owner or authorizedagent Date
Community Development
10300 Torre Avenue
Cupertino CA 95014
tV Telephone(408)777-3228
CRlf OF Fax(408)777-3333
"UPEkTINO
Buil din ; Department
JOB ADDRESS: a00 ,1,,,��j� PERMIT#
ie2
OWNER'S NAME: 5-m vS Cti ac-r—za PHONE# 2SS- '-114 3
GENERAL CONTRACTOR: .%c,,99 "&o FAX#
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I am not using any subcontractors:
Signatire Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR BUSINES 3 NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date