07050286 77777777
CITE'OF CUPERTINO
BUILDING DIVISION PERMIT + � Tt�C +QRRATI1 .
BUILDING ADDRESS: PERMIT NO.
10573 GASCOIGNE DR TBD rf0 BE DETERMINED 07050286
I'S NAME: PERMIT ISSUE DATE
ALAAELDIN AHMED 05/31/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
p O LICENSED CONTRACTOR'S DECLARATION Job Description
v p I hereby affirm that I am licensed under provisions of Chapter 9(commencing
;Ztu+r withSection 7000)ol"Division3ofthcBusincssand Professions Code,and myliccaseis INSTALL DOOR BY MASTERBEDROOM, CONVERT FAMILY
I<y in full force and effect.
License Class Lie.g ROOM
w
Date ARCHrMCTS�DECroLARATION TO MASTER BEDROOM
i a< 1 understand my plans shall be used as public records
)au
'u.in Licensed Professional
y a OWNER-BUILDER DECLARATION
> 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
3
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
<�Li which requires a permit to construct,alter,improve,demolish,or repair any structure
?Z prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
e= that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area 5 O 0
e F,$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i 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 Number Occupancy Type
not more than five hundred dollars(SSW). 375280C9 .
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure isnot intended oroffered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of q p
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.).
X4.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 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 Contractor's
License Law.
I am exempt un Sec B&P C for this reason
r Date I ��
WORKER'S COMPENSATION 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 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 Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPITON 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 mannero object to the Workers'Compensalion
Laws of Caliroroia.Date c
Applicant" 1101
NOTICE TO APPLICA ng a prion,you ahouki
become subject to the Worker's Co rovisions of the Labor Code,you must
Oforthwith comply with such, ions or this permit shall be deemed revoked.
Z'"' CONSTRUCTION LENDING AGENCY
HV) I hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
W0 Lender's Name
2 Lender's Address
V 1 certify that I have read this application and state that the above information is
L1 "^ correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
aabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Lo) liabilities,judgments,costs and expenses which may in any way accrue against said City ^ •--'7
U'Z' in consequence of the granting of this permit. Date
►'� APPLICANT UNDERS NDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATI S.
Re-roofs
Signature of for Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
',:frncd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
e,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes r0'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?
Yes Nu
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
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirement which st be met prior to issuance of a Certificate of Octrypancy t�c Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner orZstt�er zcd agent Date