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CITY OF CUPEWI'INO
BUILDING DIVISION PERMIT
h.,,�CONTRACTOR INFQRMATION s:
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BUILDING ADDRESS:
PERMIT NO0 3 110 0 5 2
A
iR'S NAME:
PERMIT ISSUE DATE
TAHEREH RAH
11/12/2003
PHONE:
SANITARY NO, CONTROL NO.
ARCHITECT /ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTORS
I hereby under provisions DECLARATION
affirm the I am licensed under r of Chapter 9 (commencing
Job DescrI tlon
p
ion 70
with Section ]Bull) of Division 3.f the Business and Pmfcssinms GOJC. and my license is
in fall fre.anderfem.
INSTALL PATIO DOOR
Liccuc Class Lice
Dam Contractor
ARCHITECT'S DECLARATION
I understand my plans shall he used as public records
Liecucd Pmfcssicnal
OWNER-BUILDER DECLARATION
1 hereby affirm Nu I am exempt from the Cnntmemes License Low for be
following mason. (Section 7131.5, Business and Professions Code: Any city or county
which Acquires a Permit m eouvum, alter, improve, demolish, or repair any structure
$1000
prior In its Issuance. also r Apiims the applicant for such Permit to tilt a signed statement
that he is lice road pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. FL Floor Area Valuation -
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
36916015.00
Nat he Is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7 031.5 by any applicant (at a permit subjects the applicant to a civil Penalty of
APN Number Occupancy Type
P Y YP
not more man five hundred delta.
❑ 1, u owner of the propeny, or my cmployces with wagesu their Ache compensation,
will do me work, and Ihcstmutum is not intended oroffercd far sale (See.7044, Business
rl
I .s
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon. and who does such work himselfor through his
/ equi ed Inspections
rl m-
owncmployces, provided Out such MIPM.Antaes are not intended moRered for ule. If.
however, the building or impommenl is sold within one year ofcompletion, om mancr.
builder will haw the burden of proving that be did net build or Improve for purpose of
/
sale.).
❑ I, as owner of properly, em exclusively
contracting with licensed convect'. m
the project (Sec. tooa4,
ct and
nd fess s Code:) The Contractor's Li-
+�
econe La
Iswdoes not apply teen owner of ny who Wilds do en,
of property who buildsorimproves thereon,or's
wh
who with
for such projeB with a conuactor(s) licensed pursuant to the Contractor's
o
ense Lace
License Law.
❑ 1 am exempt under S.C. , B & P C for this moon
j
�
f�
r �`— ' \ Dam �` \� •i
'DECLARATION
W ER'S COMPENSAT
1 hereby alllrm under Penalty of perjury one of the following declarations:
❑ 1 hew and will maintain a Certificate of Conant to self -insure for Worker's Compen-
salion, as provided for by Section 3700 of the Lather Code, for fee performance of the
work for which this permit is issued.
❑ I haw and will maintain Worker's Compensation Insursnm, At required by Section
3700 of the Labor Code, for the pe fmmsnce of the work for which this Permit Is Issued
My Worker's Com amation Insurance carrier and Policy number am:
Comer: Polity No, _
CERTIFICATE OF EXEMPTION MGM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the pmnth Is for one hundreddnlla. (SIM)
lM lees.)
1 certify that Io the Perrmmoeoe of the work for which this Permit is Wood. I shod! rim
employ any person in any manner an as to become subject to the Worecor Compcnsation
Laws of California, Date
Applicant
-
NOTICE TO APPLICANT: If. after making this Cori fiesta of Exemption. you should
become subject to the Worker's Compensation provisions of me Labor Cede, you must
forthwith comply with such provisions or this Permit shall he deemed raveled.
CONSTRUCTION LENDING AGENCY
hereby thi that merelucen(Sec. Cot, agency for the Pcrformonce of
which
the work for which this pennil Is issued (Sec. 709], Civ. C.)
3 ,
Lender's Name
Lender's Address
I certify that 1 have read this application and oak that the show information is
coricct, l Igrce to comply with all city and county onlinances and sum laws relating to
building construction. and hereby authorize representatives of this city to enter upon me
abow-menfioned Properly for inspection keep
(WC) agree I' cove, indemnify and kith City of Cupertino against
may in an w
and expenses which may in any way mcnm ego! ^A said City
in consequence nce or the
consequence ofthe granting of this Permit.
AgFLICAN7
CERE UNDERSTANDS AND WILL COMPLY WITH ALL NO POINT
S CE REGULA'i70N5. 1� �/
1� IZ>,f
Issued by: Date
�-
—
Re -roofs
Signawico ApplicaHAZARDOU Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will applicant or forum building o or handle us mammal
defined the Cupertino Municipal C'JC, Chapter 9.11, end the Health and Safety
y t aR, Chapter 9.12, Health
io
^. Sermon 255320)?
❑ Yes afWV p
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I to
Will the applicant or future building occupant use equipment or devices which
agree remove
emit hazardous air contaminants as Joined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes Po
I have read the haiAnd osma aridsmquimmenu under Chapter 6.95 of the Califor-
nia Hcolth& Sascly Coda. Scene. 25505,25573 end 25534.1 undersexed the if the building
Jars not eurtcn0y haw a anent, that if is my M%pouihiiity to ramify the Occupant of the
mquimmae which moat W met prior tV isoeanee A( Cenihcate of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owl or amhmizad agent
Date