09080003 (3) CITY OF CUPERTINO BUILDING PERMIT.
BUILDING ADDRESS: 1144 DERBYSHIRE DR CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09080003
OVA`" R'S NAME: ANWAR AWAD DATE ISSUED:08/03/2009
OWt.cR'S PHONE: 6508611354 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG r— ELECT r— PLUMB
License Class Lic.#
MECH r- RESIDENTIAL r COMMERCIAL r
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:STRUCTURAL CHANGE TO MOVE A BACK
(commencing with Section 7000)of Division 3 of the Business&Professions DOOR LEADER IN
Code and that my license is in full force and effect. THE CEILING;NO RE-RF,HOWEVER,DOES HAVE
STRUCTURAL
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 for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$800
permit is issued.
APPLICANT CERTIFICATION APN Number:36221026.00 Occupancy Type:
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Sig- re Date Issued by: Date:
I� OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation,
inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code).
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by ,ompliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this iafety Code,Section 25532(a)should 1 store or handle hazardous material.
permit is issued. %dditionally,should I use equipment or devices which emit hazardous air
1 certify that in the performance of the work for which this permit is issued,I shall =ontaminants as defined by the Bay Area Air Quality Management District 1 will
naintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's -lealth&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must owner or authori ed ager j -el/ (j
forthwith comply with such provisions or this permit shall be deemed revoked. Date: g A, (�1
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is hereby affirm that there is a construction lending agency for the performance of work's
correct. I agree to comply with all city and county ordinances and state laws relating Jor which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter ender's Name
ur above mentioned property for inspection purposes.(We)agree to save
in,- Xy and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may 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 ARCHITECT'S DECLARATION
9.18. 1 understand my plans shall be used as public records.
Signature�l.....✓ f,..-�� Date licensed Professional