00120036 CITY OFCUPERTINO -
Bon.DlNG DIVISION PERMIT CONTRACTOR INFORMATION:
IiIIILDINC,ADDC IUC10 HOMESTEAD RD PERMIT NO.
! 001.2003E
OWNER'S N s APPLICATION SUB UA'ni
tISSRIN(MII;F_) KHAZIRI 12/0E/2000
ON[!: SAN]FARY NO. CONTROLNO. ..
71.ic,nw
CHI'F17C'DENGINF.HR: - :1' - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH.-
Zlhereny aOiICENSED ONTdACICR-S DECLARE Chao erg(commencin TION Job Description
O previ.sions o gthSection7")ofDivision3oftheBusinessandProfessionsCade.andmyliccndDEMO OF GAS STgTIONin full ILtce and effect.Class Lb x _
�' Date Core rral .
ARCHII ECI"R DECLARATION •i
I welea mad my plans shall be used as....life,rua,Nx
y O O Liccnwd Podfiessinnoi'- y , ,y •,
OWNER-BUILDER DECLARATION 1
of
I herehy affirm that l tin exanpt Trent the Contmct.Cs License I.aw for the
F Z a following mann.(Section 7031 5,Business and Pec essions Code:Any city or county
IFC which reyuircs a permit to.....u ,altar,imprave,demolish,or repair any structure '
i3$ poor to its issuance,also requires the applicant fa such permum
io file a signedslateent '
that he is licensed pursuanito the provisions of be Contractor,LlcenM Law(Chapter 9 Sq. Ft. Floor Area Valuation
(commenting with Sevfion 7(00)of Desmon 3 of he Bu,mes,and Prna.,imtx Code) b 10000
or thin he is exempt therchom and the basin for the aexemption.
alleged Any violation -
of Section 7031.5 by any applicant fare Iwnnil .bj.,s the applicant m a civil penalty
arm,, nor,than fi,ehundred dollars($500) s APN Number • Occupancy Type
❑I,anw�e:anhe n,nr toemda eenwiet wn �mehaaletant afian, -
Pdlik Y ) y. gens ..ensu
will I II 'A del t t I I or offered for sale Sol, fit ,i - -
eva l I-Profession,Code, n o e, , I 1 e (ply t, to • Required Inspections'
,r it ofIthis yWho hltle prop we 01 Y t nt h d AI'edor .NO ASSIGNED . INSPECTIONS
or offerect f r bis awe arriplo,olhowever,th pmvdin for s,croveri nt is sol are ,:n' modal or
vocipil for eine.H,however, will
building t or urden of Prov is the within one year of '
infinitive
for the purpose
of rilder will have the M1unlen of proving the he diA not huild or
intpnrve for purpose of sale.). r
(lhpmpetty n I ,ivly t t ,with licensed tractors ur
on
t Ih p ) t IS ]IId4 II e s, I 1 f:Ions Cod )lT Contractor's
I<n e I u d fi t applJ t an f p petty hn bu Id pn x thereon,
1 wh t e. r :u h pro t. with a c ntrat r(,)licensed .d puant m the
urn Littnnc Law t
❑ltoo ext pt rS�a— I.- ,B kpCrrthis re.n,jwner L` We.l 'HNSAI'ION❑HCI,ARA'I'ION
I hcrchyn:dty ofpurjury one of the fallowing docliamions:1 have and Certificam of Consent to self-insure for Workr'sampen'ttion, or by Section 37(X1 of the Labor Code, for the
perfmmnceofich this..emit is issued. _
❑I have and will maintain Worker's Campenseion Insurance,as required by Secti,in
3700 of dm Latta,Gyle,for the peRornuace of the work for which this Penni,is '
issued,My Workers Con,cation Insurance carrier and Policy number are: r ,
Cartier: Policy No.: v .
CERTIFICATION OF EXEMPT ION FROM WORKERS*-
COM PENSAI']ON INSURANCE s
1 this section need(tot Is,........teed if the permit it for one hundred dollars '
' lamol ar lessd - .
I mnify the in the perfar utere of the work for which this permit is i...ed.1 '
shall not employ uny perste in any manner so as to become subject m the W kers'
Compensation Lows of Califomio.Data
Applicant
NOTICE TO APPLICANT:IL afmr making the,Cenificae of Lxemption,you should - -
hccomecu
e subjn the Workers Compensation provisions of the Labor Code,you latest' 00 O forthwith cumpiy with such powision,or this permit shall he deemed tevnAcA. _ -
,^� Ln F•ICONSTI2UCll()N1.IiNDINCACBNCY
ori I herebyffn
an thin Them is a cnxnitnnirn lending agency for the perlernnmce i
W of the work kit which'his".in Is Issued(Sou.Nair,Cit..C.)
Q Lender's Ntme 's s
z lancer's Address
I C.7 'I certify dint 1 have vanillin k applicmion and store that the above ink nrnreturn is
Iia E.. earner.1 agree it,comply with u1I city and county ordinances and stet lows relating
^0 V rebuildingconstruction.and hereby teharim representatives orthis city m enter upon s
w the howe of ntioned property for in,penina purpnex.
.r d (We)agree(it save,iaiannity and keep harmless the City of Cupenino again
VJ City to conudgmems,costs and expends which may in any way uccme again..said = j
•,V City
U�ND2gf the gmtNA of t TILL COMPLY WITH ALI.NON 7/1
INT
souncH�qry poy-- �� / Issuedb 7 Dat
'fit e tAn Itanucaam lm Dat, — ,Re=roofs .
HAZARI ti ATBItIAS DISCLOSURE d
WI lscappllcamar' orchid lingrv.'nlpant,IorunPl,andlel eurdoui seerial' Type•of Roof
as defined by the Cupenil Mun la Fe Cale.Chapter 9.12,and tine feallh d Se etya -
Code,.Seectio13 sn25532(x)'! ❑Nn w• - ,
All rool's shall be inspected prior to any roofing material being installed_.
Will theappEe: Iaramre lildfngtweapantuseegmpnmatordeviceswhich 'If a roof,is installed without first obtaining an inspection, I agree to remove.
.nit h...Nuus sur con defined by the Bay Area Air Quality Managanea
amen .all-new materials forinspection. Applicant understands and will comply with-
0
Ya. - ' 0 N all non-point source regulations. -
I have read the hazedous mamrial,requirements under Chapter 6,95 of the
Calitimnia Health&Safety Cnde.Sections 25503 5533 and 25531 I understand thin '
illhehuildingdnenn,nreov, ylvrvuuhnlnn, ut it`` ymsponsibility Inn lye
cel t f the e 1 Ire t' hl ll cul: p r a a Ce tcme f
()ce I't Y
(�M Signature of Applicant bate t
awl , ,l tlf, ed eat ox All roof coverings to beClas•sB" or better
'OFFICE