04060137CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
777'
BUILDING ADDRESS:
RAY NE7iIII.AD
PERMIT NO04060137 4060137
22561 RICAR
OWNER'S NAME:
PERNUT ISSUE DATE
RAY NEZHAD
10413 TORRE AV7. 4700
-/
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with 7000) of Division 3 of the Business and ons Code, and my license is
Licanae Class Lie. fol and effect /
Lk � ¢J oz. �-
NEW 2 -STORY SFDW (2872 SQ.FT. LIVING SPACE)
GARAGE 433 SQ FT
Data Contractor
ARCH ECf-S DECLA ON
. .
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the '..
following reason. (Section 7031.5. Business and Professions Code: Any city or county ''....
which requires a Permit to construct, alter, improve, demolish, or mpair any structum '..
prior to its issuance, also requires the applicant for such Permit to file a signed statement
that he is licensed pursuant to the provisions of We contractors License Law (Chapter 9
Sq. Ft. Floor Area
Va"to 0 0 0
(commencing with Section 70Do) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
35601053.00
❑ 1. as owner of the property, or my employees with wages as their sole compensation.
Required Ins eetions
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Cade: The Contractor's License Law does not apply to an owner of
q p
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 offered for sale. If,
however. the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build Or improve for purpose of
safe.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improve thereon, and ,
wlpo connects for such projects with a contractor(s) licensed pursuant to the Convector's
,
L nse Law.
1 am exempt under See. . B & P C for this reason
OwnJ(i1_.
WORKER'S COMPENSATION DECLARATIONC
I hereby alum under penalty of perjury one of the following declarations:
❑ 1 hart and will maintain a Certificate of Consent to self -insure for WakcesCanpen-
sation, as provided for by Section 3700 of We Labor Code, for the performance of the
work for which this permit is issued
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of We Labor Code, for the performance of the work for which this permit is issued.
'
My Workers Compensation Insurance carrier an oliey number are:
Cprriar: olicy No.:
(1 CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
r
('iris section need not be completed if the permit Is forone hurdmd dollars (5100)
or Icss.)
I certify that in the performance or the work for which this permit is issued, 1 shall not
employ any person inanymanners a_sto bccorrm subjecitothe Workers'Compensation
Laws of Cali nn t
Applies u z
NOTIC APP IC • , afer acing tiias Certificate of Exemption, you should
become ect to the Workers Compensadpn provisions of the Labor Code. you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's address
I certify that 1 have read this application and state that the above information is
cortcoL I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorve representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and beep harmless the City of Cupertino against
liabilities, Judgments. costs and expenses which may in any way accrue against said City
in consequence of the granting of this permiL
APPLICANT UN STANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
R O
Re -roofs
Type of Roof
_S941RCF
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OS(fnaunns of Appticant/Contraclor D
HAZARDOUS MATERIALS DISCLO RE
Will the applicant or future building occupantstom or handle humdous material
as defined by the Cuperdno Munici al Code. Chapter 9.12, and We Health and Safety
Code. Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant sere equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Managcmcnt
all new materials for inspection,
Disuict7
❑Yes u
I have real the hazardous materials requirements under Chapter 6.95 of the Cal ifor-
niaHealth&SafctyCode, Sections 25505.25533 and 25534.1 understand that if We building
does not currently have a tenant that it is my responsibility to notify the occupant of the
rcquucments whic�inusl bC et prior to issuance of a certificate of Occupancy.
Signature of Applicant Date
A11 roof coverings to be Class "B" or better
Owper ser authorized agent _ _. pate