07100111 REV1 CITY OF CUPERTINO ` ' ' ` '
BUILDING DIYISION PERMIT ���'�R� �'��� Z����������
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BUiLDING ADDRESS: PERMIT PIO.
18881 ARATA WAY ADVANC D DEVELOPMENT/JACOB 07100111 �
cR'S NAME: �T PERMIT LSSUE DATE
JACOB SAIDIAN 29 B �NJAMIN
PHONE: SANITARY NO. CONTROL NO.
ARCHI'fECT/ENGINEER: BU►LDING PERM1TiNF0
REVSN; ADDING DETAIL BASMNT HLDG ELECT PLUMB MECH
� � � 0
i p 0 LICENSED CONTRACTOR'S DECLARATION JOb DeSCflpt1011
� V � I hcrcby affirtn �hat [ am liccnsed uncier provisions af Chap�cr 9 (commcncing -- - ----�- --- -.-- --� -�---- _-- - --- — --- -
; z� with Sec�ion 7000) of Division 3 of ihc Busincss and ProCcssiuns Cadc, and my liccnsc is
'� y in full Coree and cftect
� v� z Licenx Class L�. #
� t, � Datc Conuacinr
� ARCHITECCS DECLARATION
i a Q I undcrstanJ my plans shall bc uscd u public rccordc
)yV
' u. y Licensed Pni[cscional
� y � OWNER-BUILDER DEC[.ARATION
>' 1 hcrcby atTirm tha� 1 am cxcmpt from U�c Contractor's Liccnsc Law far thc
j �� foliowing rcason. (Sccuon 7031.5, Busincss and Profcssions Codc: Any city or county
�$ which rcquims a pertnit to conswc4 alter, impmvc, dcmnlieh, or mpair any sweture
� Z y prior u� i�s issuancc. alsu rcquires ihc applicant for such permit ta filc a signcd sutcmcm , Ft. FlOOi AI'E3 Valuation
��< thai hc is liccnscd pursuan� �o thc provisions oC thc Convacwr's Liccnu Caw (Chapicr 9 :��]
� F- �(commcncing wiih Sccuon 7000) of Division 3 a( Ihc Busincss and Profcssinns Cadc) or
,�, �� that he is ezempt thcretrom and Ne basis Cor the allegcd eumption. Any violation oC
Section 703I.S by any applicant for a pennit subjccu �hc applicant to a civil pcnalty of APN Number Occupancy Type
not morc �han five hundred dallars (5500).
� I, ss owner oC ttie property, or my employcu with wages az the'v solc compensation,
arill do thc work, and U:e strucwre is no[ in�ende� or of[eceG fo� salc (Sa.7044, Business Re uired Ins eCtIOIIS
and Pevfessions Codc: The Canuacror's License Law docs not apply w an owne� of q p
propeny who builds or improves �hercon, and who does such wurt himul[ or throngh his
awn employces, providcd U�at such improvemen�s are not intended aro[Lered forsala IC,
howevu, the building or imp�ovement is sold within one yesr of compledon, d�e owner-
builder will have the burden o( proving �at he did not build or improvc for purpose af
sa�.).
I, as owner oC the property, am ezclusivety conuacting wiU� licensed rnnuactors w
conswct the project (Sec. 7044, Business and Professions Code:) The Conuutor's Li•
ccnse Caw docs not apply to an owner of propeny who builds or improves Wemon, and .
who convacls for such ptojects with a con�ractor(s) licensed pursusnt to Uu Contrxtoc's
License Law.
^ I am aempt undu c. , B 8c P C f r Ihis n
rcr C.Ya C �� G' Date/ �p �� _. .
WORKER'S OMPENSATION DECLARATION
I hereby afficm under penalty of perjury one o( the following dxlarations:
❑ I hsve and will mainuin a Cenificate of Consent to self-iasurc for Worker's Compen-
sation, as provided far by Section 3700 of the Labor Cade, far the performance o[ the
worlc for whieh Ihis permit is issucd.
❑ I have and will maintain Worker's Compensauon (nsurance, u myuired by Scction
3700 of thc Labor Codc, for thc perCormance of the wwt far which �his permit is issued.
My Worker's Compensatian Insurance carticr and Policy number aze:
Carrier. Policy No.:
CER7'IFICATE OF EXEMP!'[ON FROM WORKERS'
COMPENSATION INSURANCE
(This scction necd not 6c complctcd if the pertnit is for onc hundred dotlars (S I00)
or Icss.) '
I ceni[� U�.t in ihc performancc of the work for which this pertnit is issucd, t shall not
employ any person in any manncr so az to bccomc su6ject w �he Workcrs' Compcnsadon
Laws of Califomia ��tc_ � ! �\
Applicant „)
N01'ICE TO APPLlCANT: If, alYcr making this CertiGcatc of Excmpuon, you shauld
become subjcct to ihe Workcr's Compcnsation pmvisions af Wc La6ar Codc, yau must
�,Z fonhwi�h comply with such provisions or this permi� sha116c dccmcd mvokcd.
z O CONSCRUCTION LENDING AGENCY
E ►�-� I hcrcby aRrm that �hcre is a conswction Icnding agcircy for ihc perCortnancc of _
�'(, � �hc wurk fur which Utis pertnit is issucd (Scc. 3097, Civ. C.)
W� Q Lcndcr's Namc '
� z Lcnder's Address
U � 1 ccrtifY thal 1 havc rcad Ihis application and siatc �hat thc abovc informatiun is
w � cortcct. 1 agree to comply with all city and county oniinances and state laws rclating �o
� U huilding conswct�on, and hcrcby authori�e rcprcscntativcs of this city to cntcr upon thc
� a aM1ovc-mcntioncd property for inspccuon purposes.
(Wc) agrce to sare, indemmfy and kecp harmlcss ihc City oC Cupcnino against
�„�„� � liabiliva, judgmcnts, costs and cxpcnscs which may in any way acccuc against said City
V,'� in consequcncc oC granting of this permit. 7 l,���
�"� APPLICANT U STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date /Q� �
SOURCE R noNS. � e I� ^ ��
� � Re-roofs
ure o pplicant/Convactor Datc
HAZARDOUS MATERIALS D[SCLOSURE Type of R � )Of
Will thc applican� or futurc building occupantstorc or handlc haiar�dous matcrial
tcfined by the Cupenino Municipal Codc. Ct�aptcr 9.12. and thc Hcalth and Safcty
�, Scction 25532(a)? All roofs : hall be inspected prior to any roofing material being installed.
� ycs �] No
Will the applicanc or Cuturc building occupant usc cquipmcnt or dcviccs which If a rOOf 1 installed without first obtaining an inspection, I agree to remove -
emit harardaus air conu �nan�s as dcfincd Ay �he Bay Area Air Quality Managcmcnt all new m; iterials for inspec!ion.
Disuicc?
❑ Ycs � Nu
1 havc reaA the ha�ardous ma�crials requircmcna undcr Chaptcr6.95 of thc Cali(or-
nia Hcal�h & Safcty Codc, 'ons 25505. 25533 a�u125534.1 urnkrsund �hat if �he 6uilding
ciocs not curtently ha unan4 that i� is my responsibility w nouCy thc occupant of �hc
rcyuircmcn�s w' t bc me� pcior to issuancc oCa Ccrtifica�c of Occup • S1gIlfltlllC �f Applicant Date
�v�rorau�horizcdagcnt '' ` p� All roof coverings to be Class ��8�� or better