06010039pp
og
Ain.
`bt;
0
Troy
Km4.
Y�y
d
i
CITY OF CUPERTINO•#�.>
BUILDING DIVIs10NPERMIT
CONTRACT.OR,�N�FARMA,aION
BUILDING ADDRESS:
9RF N PORTAL AV
PERMIT NOQ 6 010 0 3 9
OWNER'S NAME:
PERMIT ISSUE DATE
AHMAD
01/09Z2006
PSAGHEER
E:
SANITARY NO, CONTROL NO.
ARCHITECT GINEER:
BUILDING PERMIT INFO
ELECT PLUMB MECH
wenf,y7,
LICENSED COMRACTOrp DECLARATION
1 ionby affirm Nel 1 em under provisions of Chepser 9 (rommense
Job Descri tifjn
p
ftheud
with Section )IX1U) ofDivision l of the Businessand Pro@cions CWe, and my license is
is
std tuo Lia
infull mrccand.frect.
RETROFITTING WINDOWS (9) &
Lic.nse Class Lla.N
Dam Contractor
PATIO DOOR (1) JAN � ZOO6
ARCHITECTS DECLARATION
1 undersand my pIm..hall W used as public rca.,&
Licensed Pnsfcuianal
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from Ne Contractors Liccnu law for Oe
following mason. (Section 7031.5, Business and Professions Cade: Any city or county
which requires a pcmdl la construct, altar. Improw, dcmoll.h, Or repair any structure
prior tons ismance, also rcquircs the applicant forsuch pcdril to file a signed sutamenl
that he is licensed pursuant o the previsions of the Conuscbri License Law (Chapter 9
Sq. FL Floor Area Valuat 5 0
(commencing with Section 7") of Division 3 of the Business and Professions Choc) or
that M is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by tory applicant for a permit Subfeea the applicant n a civil penalty of
not marc Nan Rn hundred dollam (s5W)k
APN Number
Occupancy Type
31629002.00
❑ 1,asowncrofshepmpmy,ormycmplo wiNwaguulh'uwlecmdpermdon,
will do Ne wmis and Ne shoelace is not intended or OBcrt4 0w a d e (Sec. 7W. Busbrar
and Professions Code: The Commune, Liaise Law does not apply to .n owner of
Required Inspections
property who builds or improve Ncreon, andwho dmssuch work himself orthrough his
Own employees, provided Nal such improvements are not intended oroRered for sale. If,
however, Ne building or improvement is sold within one year of completion, Ne owner.
builder will baa Ne burden of proving Nat be did not Wild or improve for purpose of
sale.).
❑ 1, as owme of Ne property, am exclusively contracting with licensed comraams to
construct Ne project (Sec. 7Wd, Business and Professions Code:) The Coometm's Li-
cense taw docs not apply to an Owner of proanywho Wilds or improves Nesron. and
who contacts fm such plojeeu with a Contractor(s) licensed pursuant to the Commander
License law.
❑ I amuempmou",�Sta�x,� ,B&PCfm Nismason
nee 5�3.�VNAfI Data s''1 0 O�
WORKERSC PENSA730N DECLARATION
1 hereby Nm under penalty of perjury aro of the following declarations:
1 have and will maintain aCenifiale of Consent to self -imam for Wma ri Compen-
alion, m provided for by Session 37M of the Labor Code. for Ne perfmmana of the
wok for which this permit is issued.
❑ 1 have and will maintain Warder's Compensation Introduce. u required by Section
3700 df the tabor Code, for Ne performance of the work fmwhich this permit is issued.
My Wdrkaer Compeuation Insurance canis and Policy number arc:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not W completed If the permit is for one hundred dollars ($ sal)
at loss.)
I sonify Nat in Ne performance of the work far which this permit is issued. l shall not
employ any petard In my mannCr m es b bCepmC Suyyfeel le the Workers Coral enation
Laws Of Callfdmia Dam ol/t-r9 /..l.
Applicant_ •sen.
NUHL4 TO APPLICANT: If. after making Nu Lenlfcem of Exemption, you should
bottom subject to the WOrk x s Compensation provisions of ncc labor Code you mart
forthwith comply with such Provisions or this permit shall W deemed lev.kcd.
CONSfRUMON LENDING AGENCY
I hereby Nem that Nen is a construction landing agemy far Ne performance of
the work for which this permit Is issued (Sac. 3W7, Civ, C.)
Landcr's Name
Loodcrs Address
1 certify that I have rad this application and sou Oar Ne above information is
tate% I agloe b comply with All City and county ordinarcu and state laws relating to
Wilding conswction, and hereby euNorire mprom utiver or Ihucity to color open the
ahovomcnudgm property for Impaction
(We) agree 10 save, indemnify and keep hannlest the City of Cupertino against
costs and expenses which may in any way rectae against sold City
which may
lieconsequenc
or Me
in consequence Of the gmnling of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:
SOURCE REG LATIONS.
Date
617. 01/07k/Re-roofs
5ngnsmre lnanU of Apponmcmr Oslo
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future Wilding Ottvpant nose or handle herudous material
u do nen by Ne Cupertino Municipal Code. Chapter 9.13. and the Health and Wet,
Code, Section 25532(a)?
❑Yes ON.
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, I agree to remove
nil hazardous air conuminanss as defined by the Bay Arca Air Quality Management
I5VICIT
all new materials for inspection.
Q Yes ❑No
I have road the hvodlecamatarials acW inmcnu under Chapmr6,95 ofNc Califor-
nia Health & SufalCode, Statuses 25.515.25533 and 25534.1 wbcrnmM Nuif Ne Wilding
does not currently have a leaam Nm it u my nommoubtlity no notify Ile oaupanl of the
rcquiromcroswhi It must bemn prior to inaana dip Ceekate oroccoparny.
Signature of Applicant
Date
All roof coverinias to be Class "B" Or heft,,
Owner oraummbed.geml Dane