02110105 CITY OF CUPER'I'INO s' w W, - r "-se, "Y y,
BUILDING DIVISION PERMIT CONTRACTORANFORMATION
BUIfJ)@'60IgtI7sFLORA VISTA AVE COSTELLO CONSTRUCTION PERMIT N02110105
owffOOKSON & GIGI SAPURDAR 10625 FLORA VISTA AVE APPLICATTIISI/ TIP H2O02
HONE:
(408) 257-9419 SANITARY NO. / CONTROL NO.
ARCUITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
are,
LICENSED CONTRACTOR'S DECLARATION D `��
rc�2F I hereby arum that l am licensed under provision of Chapter 9(commencing INSTALL GAS FI' $HbNrlptlon r E'41
<i with Section ion 71XM1)nl DivisioBusinesse Business and Professions CnJe.and my license is
in full force and effect.
z 0l9 Litems Class Lic.x
FynData Gnmmnor APR 0 4 nR2003
H
ARCHCTS DECLARATION
�y,eaQ I understand my plansshall W used as public records
n OwU
Via e. Licensed Professional BU'1 Da1�
—O `� OWNER-BUILDER DECLARATION S
CMM I hereby athrm shut I oro acmpl from the Comtmclads Liwnc Law for the 2 6 O O
a FOO followingMason.(Section 7031.5.Business and professions Coda:Any Ciyo,emmy
X
$ which requires a permit to consumer,alter,improve,demolish.or repair any.orucmre
rza
prior o its issanea.also requires the applicantfor such permit to file a signed statement
that he is licensed pmsuenfso the provisions of the Contractor's License Law(Chapter 9 3S2461raMQb8A@0 Valuation
ml" (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
w R E that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 703 L5 by any applicant for a permit subjects ft applicant to a civil penalty off`N N
not tome than rive hundred dollars($50(p. C11 1\ Occupancy Type
❑ 1,as owner of the prepmty.ormyemployees with wages atheir sulecompensation, 312 — CHIMNEY REBA & STRAPS
will do the work,and She structure is not intended oroffered hostile(Sm.70 4,Business II
and Professions Code:The Convector's License law Jas not apply to an owner of egUITC nspeetlOns
property who builds or improves thereon.and who docssuch work himself orthmugh his
own employees,pervided that such improvements are not intended m offered forsale.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
salt.).
I,as Owner of me property,am exclusively tonVacting with licensed contractors to
street the perfect(Sec 7W.Business and Professions Cuda:)The Convutor's Li-
ttre law docs not apply to an owner of property who Wilds or improves thereon.and
who contracts for such projects with a conuaca r(s)licensed pursuant to the Contractors
License law.
❑ lam exempt unmt,ey ,B&PC for his..,in
O�Svna 1 Dare �/1 1�'u
OR OMPENSATION OLCLARA�
1 e ser penalty of Perjury on of tha following daelaralnns:
I have and will maintain a Ce ificafa of Consent In self-inurefor Worker's Compen-
sation,as provided for by Section 3710 of the labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3710 of tht labor Code,for ma performance of the work for which this permit is issued.
My Worker's Compensation Insurance carie,and Policy number are:
Callen Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
olik.vcction need no W cnmplawd if tW Non it is f isnot hunmcd Dollars(SRxB
lass.)
1 certify that in the perlixmam a of the work for which this permit is issued.1 shall not
employ any person in any manner so as to become subject u,the Workers Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making fair Ce ificate of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you most
oz forthwith comply with such provisions or this permit shall W deemed revoked.
z O CONSTRUCTION LENDING AGENCY
[-�
I hereby affirm that mere is a COnlmCllon lending agency lot the porlornmem of
a me work for which this permit is issued(See3097.Civ.C.)
lL)Q Under',Nam,
UZ) z 'a Larri Address
V 0 I certify that 1 have real this application and diza that the above information is
OF^ nmdingcoagree mcomply wileall city yaumri countyordinancesand laws enter
upon line
,
V abovenmentiomniomand hereby aumonprposescnutires of this my reenter upon he
abnvcmeei agree
Property Save for inspection purposes.
H 4 We)agnea m save,indemnify and keep harmless the Circ of against
against
In Iiaconsequenc of the grand
of this esmit. may in any wayacme against said Coy
V z in consequence of he gaming of this permit.
�^ APPLICANTUNDER TANDS AN WILL COMPLY WITH ALL NON-POINT Issuedby: Date
SOU CE L ONS_ J/l/�"q
Re-roofs
Sig t fApplicxnJC ter r r
HA'LA DOUSMATURIALSDISCLOSURE 'W Type of Roof
uWill fpr pplic.mo,��mfc Whimgnocupxntsmrc urhanJlc hararluus mammal
Jefin l.1a,"e�C;rpe d Municipal Coda.Chapter 9.12,and the Health and Safety
Code,Section 25532fa)7
❑Yes 6kNu All roofs shall be inspected prior to any roofing material being installed.
Will the aPPlicam or fuwrc building Occupant use cyuipmem or devices which If a roof is installed without fool obtaining an inspection,I agree to remove
'mit haeardnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Owner?
❑tie's t9No
I have mad the harallous mumcnalsreyuirements under Chapter 6.95 of filo Califor
ria Health S Safcty C,de,Sectors 25505,25533 and 25534.1 underafand that ifha Wilding
does not currently have a Leant that it is my resporuibiliry m notify IN OmUrpant of me
myui¢mens Soh etnnmto iopearce of.c,n,li,am -0.,um,ay. Signature of Applicant Date
Ownernr r,.eda Data All roof coverings to be Class"B" or better