02090060 CITY ®IF C UP EIIg7 ENO d v
DEMO
APN# // _ Date:
Building Address: l (o
A-v,.
Owner's Name: Phone#:
'l- 2 dUlAA)7- 4-59PIA /F
Contractor: P-81c- � �� r -06�5-q
3� License#:
Contact: r r�A U/�! � Phone�#:D
f T �
Applicant/Contractor: � �\ Lo
Build g P rmit Info:
Bldg Elect Plumb Mech
Job D cription:
esidential: Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupancy rou :
Qty. if
Appl4akbilb, Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG
- ` r 7
CIITY®IF CUPERTINO
BUILDING DIVISION �� (CONTRACTOR LN701RMA IYa
BLnLD[NG ADDRESS: Y PERMIT NO.
II 18831 TILSON AVE . 02090060
0 S AME: APPLICATION SUB DATE
A NADERI ZANIA_TNI & SHEVA 09/10/2002
PHONE: SANITARY NO. CONTROL NO.
0 oe Z, ARCHITECrfENGINEER: BUILDING PERMIT INFO
v o a BLDG ELECT PLUMB MECH
U 'I r -I LJ L.J
y Za'
F N' LICENSED CONTRACTOR'S DECLARATION
Z Z y 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing0. Job Description
0 m[_.Eli with Section 7000)of Division 3 of the Business and Professions Code,and my license DEMO
C Y g;; is in full force and effect.
z C 4 License Class Lic.#
a 0 a V Dare Contractor
3 u_ ARCHITECT'S DECLARATION
E-a to�J I understand my plans shall be used as public records
f EI -
uull p Od Licensed Professional
a XaX oOWNER-BUILDER DECLARATION
u]=to I hereby affirm that I am exempt from the Contractor's License Law for the
following reason.(Section 7031.5,Business and Professions Code:Any city or county $9000
O� which requires a permit to construct,alter,improve,demolish,or repair any structure
riot to its issuanec,also requires the applicant for such ermit to file o signed statement
that,he is licensed pursdam to the provisions of the Contractors License Law(Chapter 9 Valuation
(commencing with Section 7000)of Division 3 of the Business and Prof ssions Code) 3 tb`O a'"r' a^.�' ,y,�� j P f'•i
or that he is exempt therefrom and the basis for the alleged dxemption.Any violation, i
� of Section 7031.5-by anyapplicant fora permit subjects the applicant to a civil penalry
' of.not more than five hundred dollars($500). No AM VantJ INSPECT ONSt`' Occupancy Type
1 ❑1.as owner of the property,or my employees with wages as their sole compensation,
I` will do the work;and the structure is not intended or offered for sale(Sec.7044.-
Business
044;Business and Professions Code:The Contractor's License Law does not apply to an Required Inspe'c'tions`r '
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
N.offered for sale If,However;the ouildingorimpmvement is sold within one year of
completion,the owner-builder will have the burden of proving that he did not build or
i rove for purpose of sale.).
_ I,az owner of the property,am exclusively contracting with licensed contractors to _
,i onstruct the project(Sec.7044,Business and Professions Code:)The Contractor's ,. r ..;_t
License 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 icense Law.
❑lam
ex
c St under Sec &PaC for is reason - `..(i?)�:��'1
_ rte.7- Date II I,I
. WO C COMPE TI N DE��RAT N
I hereby affirm under penalty of per ry one o(the following declarations;
❑ l have and will maintain a Cenificate df 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 Wbrkers Compensaiion Idsuiance,as required by Section
3700 of the Labor Code for the performance of the work for which this permit is
issued.My Worker's*Compensdtion Insurance carrier and Policy number arc:
Cartier, "Policy No.:
•_CERTIFICATION OF EXEMPTION FROM WORKERS' •• .•t
•' - COMPENSATION INSURANCE -
(This section need not be completed'if the permit is for one hundred dollars
(SI 00)or less.) I
1 certify that*in the perpo nee of the work f r which this permit is issued l --
shall not emplo'any person in an verso o corn sub'etx to the Workers
Comp nI. __ ws of CalifoNa. a t
App' -
N ICE TO P ;•IRer making this Certificate of Exemption;you should ! ,
�j Be e subj ct to the Wr air's Compensatibn provision'sof the Labor Code,you must
® ® forthwith comply with h provisions or this permit shall be deemed revoked.
Mt I hereby affirm that there is a construction lending agency for the
Q of the work for which this permit is issued Sec.3097,Civ.C. - performance
�
CONSTRUCTION LEN M AGENCY
e e Y Pe
P )
� Lender's Name
t� Lender's Address - •-- r:i ,,,.. - -.�._..-- - --- --
®! 1 certify that I have read this application and state that the above information is
�i correct I agree to comply,with all city and county ordinances anq state laws relating
® �f to building construction,and hereby authorize representatives of this city to enter upon
6� the above-mentioned property for inspection purposes..
'(We)agree to save,indemnify and keep harmless the City of Cupertino against /.
b rA liabilities,judgments,costs and expenses which may in any way accrue against said
a
e'of the grani 'of this permit.
81iSTA1� D WILL COMPLY WITH ALL NO PAVO,NSIssued by Date
ant/ nt star Dn[ Re-roOFS
as Code,ned by the Cupertino Muni'Pat Code,Chapter 9.2,and the Health and Safety Type Of ROOF._. _.._._... _. .__.._ __.. ....._...... .__.
H RDOUS MATERIALS DISC OSURE
Will thea tic or future Wildingoccupant store or handle _
Health and Safety t •l r.,t '..' - ..,'. _.. .._ _ ..
❑Yes ''•�� No
All roofs.shall-be-inspected prior to any roofing material_being.installed...,__-_..
.. _
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection;'--1-agree to remove
emit hazardous air contaminants as defined by the Bayrea AAir Quality Management
District' all new materials for inspection. Applicant understands and will comply with
❑Yes N° all non-point source regulations..,,.. i•.,,' - -
I have read the hazardo s materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
iP the building does not currently have a tenant,that it is my responsibility to notify the -
accupant o the requtrerhents ich must be met prior to issuance of a Certificate of
QeG°Pam Signature of Applicant Date
nerd as ized,a nt All roof coverings to be Class `B"or better
OFFICE ..