12050103 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 21622 COLUMBUS AVE CONTRACTOR: \1AIER I I l AFERS ONLY PERNII'INO: 12050103
OWNER'S NAME: RG%AI-FAKIIR M G 13T AL 970 E MAIN SI' DAIT ISSUED:05/102012
OWNER'S PHONE: 4082578684 GRASS VALLEY.CA 95945 PHONE NO:(8at)835-5946
❑ LICENSEI)CON'TRACTOR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class IJc.N MECIi RESIDENTIAL COMNIERCIALr
Contractor Date.
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTIONRIiMOV19KHP1.ACli GAS N',\'I'IiR III:.\'I'IiR
:
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation.as provided for by Section 3700 of the Labor Code for the
performance of the work Ibr which this permit is issued. Sq.Fl Floor Arca:0 Valuation:S980
1 have and will n ainmin Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN Number:35618051.00 Occupancy'I'ype:
A I'1'I,ICAN'I'CER'1'IFIC,\"PION
I certify that I have read this application and state that the above information is
correct. l agree to comply with all city and county ordinances and slate laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We.)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses n'hich ntav accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code.Section Issued by: [)site:
9.18.
Signature Dale
RF:ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed. If a root'is
installed without first oblaining an inspection.I agree in remove all new materials Ibr
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following Iwo reasons:
I.as owner of the property,or my employees with wages as their sole cumpensal ion. Signatrue of npplicml: Date:
will do the work.and the structure is not intended or oitered for sale(Sec.7044.
Business&Professions Code)
h as owner of the property,an,exclusively contracting with licensed contractors to ALI.ROOF CO%ERINGS'1'0 RE CLASS"A"OR RE]'I ER
construct the project(Sec.7044,Business&Professions Code).
1 hereby affirm under penalty of perjury one of the following three IIA%ARDOUS NIA I ERIAI,S DISCLOSURE
declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to sclf-insurc for Worker's California Ileallh&Safely Code,Sections 25505,25533.and 25534. I will maintain
Compensation,as provided f'or by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
perlimnance of the work for which Ibis pertnil is issued. Safety Code.Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emir hazardous air
Section 3700 ofthe Labor Code,for the performance of the work for which this contaminants as defined by the Ba' Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.122 and the
permit is issued. IIeallh&Safety Code,Sections 25505,25533,and 25534.
1 certify that in the perlimnnnce ofllte wok for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation laws of California If,after making this certificate ol'exemption,I Date:
become subject to the Worker's Compensation provisions of the labor Code.I must
forthwith comply with such provisions or this permit shall he deemed revoked. CON:S'1'RtiCflON I.EN'DING:\GF.NCY
I hereby affirm that there is a construction landing agency hhr the pertbnnance lit work's
APPLIC\N'f CERTIFICATION lou which this permit is issued(Sec.3097.Civ C.)
I certify that I have read this application and slate that the above information is Lender's Name
correct. I agree to comply with all city and county ordinances and state lass's relating
10 building construction.and hereby authorize representatives of(his city to enter Lender's Address
upon the above mentioned property for inspection purposes-(We.)agree to save
indemnify and keep harndcss the City of Cupertino against Iiabilitics,judgments. ARCH fl'ECI'S DF.CI._%RA IION
costs,and expenses which may accrue against said City in consequence of the
granting of this penin.Additionally,the applicant understands and will comply I understand my plans shall he used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9,18. Licensed Professional
Signature Date