06020089 CITY OF CUPERTINO z*+�r• 1 ` `t•' `
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION .„
BUILDING ADDRESS: PERMIT NO.
10518 STERLING BLVD
NER'S NAME: PERMIT ISSUE DATE
BAHRAM SHAMLOU 03/24/2006
PHONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECrPLUMB MECH
jos LICENSED CONTRACTOR'S DECLARATION
e u afrom
Nat 1 am liccvcd under provisions of Chapter 9(Commencing Job Description
Czul withSection70lV)ofDivision3ofNeBusinessandPaiminnsCode,andmylicenseis DEMO (E) HOUSE
6
in full tutee and crtce
l.
j ig Z License Class Lic.p ,
Da¢ Comrxwr
ARCI1rIECPS DECLARATION
¢< I undersand my plans shall W used as public records
Jto
sat, Licensed Professional vv�
g OWNER-BUILDER DECLARATION
<I I reaMe affirm that I i. exempt from thefessins Co :Anyc Law for the
e o following massa Permian RO LS Business and vee.de um Code:Any city of county \ ' $8000 8,0 O O
5 m which its i ms a permit to ennatruc,,alma improve,demolish,fi rasa any structure
Y
z y prior m its issuance,also mgoires the,applicant toe such Permit to s signed statement
££S< (that he commesccgwithSrsuanunth)ofDivioasn of the
LiccnuLaw(ChapmrY Sq. Ft. Floor Area Valuation
set-$ (commencing with Scnion 7")of Division Jsf Ne Businev and Profcssism CnJc)or
dust W is exempt draeform sold tat basis for the alleged Assumption.Any violation of
Section]031.5 by any applicant for a permit subjects the applicator a civil penally of Um er Occupancy T
not mom than five hundred dollars(M). P Y YPe
C1 I,u owner of the property,ar my employees wish wages as their ale compensation,
will do the work,and the structure is not intimated or offered for sale(Sec.7014,Business
And Professions Code:The Contractors License Law does not apply to an owner of Required Inspections
property who builds or improves dremon,and who dm3 mAh work himself or through his
own employ=,provided that such improvements are not intended oroRered(mule.If.
however,the building or improvement Is mid within one year of completion,she owner-
builder will hole the burden of proving that Ir did not Wild or improv:for perpmc of
tile.).
1,ss mw of the property am exclusively contacting with licensed contactors to
construct the project(sec.7044,Business and Professions Code:)The Contractor's Li
cense Law does not apply M in oww of property who Wilds or improves thereon,and
who contracts for such pmKets with a contractor(s)liesm ad pursuant to the Contm mere
License Law.
❑l am exemptun Sec /,.. —,B l P C for this mason
net f /J LLAri'e�. Data
WO COMPENSATION DECLARATION
(hereby af0mr under penalty,of perjury arc of the following declemtiom:
L haw and will maintain a Ccnificate of Cmaenuoself-insum fm WorkersCompcn-
sadon,as provided for by Section 3700 of the IoWe Code,for the performance of the
work for which this permit is issued.
❑I lave and will maintain Worker's Comperoation Imuance,as mquiud by Section
3700 of the Labor Code,for the performance of she work for which this permit is issued.
My Workers Compenntion I...artier and Policy number are:
Carie,: .Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
CIEs section mad not W canplcted Kiat permit is fm one hundred dollars($100)
m less.)
1 certify that in to performance of the work for which this permit is Wood,I shall not
employ any person in any answer Ad a inerne suhicet to the Workers Compensation
Laws of Califomia.Dam s / 2�
Applicant t 1 -krx— '4!1/O?!
NOTICE TO APPLICANT:If,afdr making this Ccni(icam of Excialution,you should
become subject a she Worker's Compeazation provisions of the Labor Code,you muss
.Jz foMWith comply with Such provisions or this permit shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
PI hereby arfrm Nat then iso coaSuuNsn lending agency for the performance of
a she work for which this permit is issued(sec.3097,Civ.C)
W❑ Lender's Name
5 z Lendeh Add.
U Q I certify that I have read this application and sum that the above information is
D.P ctrl 1 agree to comply with all city and county ordinances and mute laws relating to
(]U Wilding Construction,and herby Monodic ormaentatives of this city to enter upon the
abovemcmidgin propery for inspection pugwuz
E�„y
(WC)agree to save,indemnify and keep hmmless the City of CUPer ins against
Z Iiabilitieajudg Cribs wooing eapcnuswhich may in anyway accmc againstsaid City /
Uz A APPLICANT
Cribs of NisD WILL
'—' APPLICANT ULATIONANDs AND WILL COMPLY WITH ALL NON-POINT Issued by: Date -f
SOURCERE p �
X5� '�/�45 Re-roofs
Signaturc of Appbc Comtracmr S per/
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Cu-rut=building secupamutom or handle hmardous mamlal
ax defined by the Canadian Municipal Code,Chapter 9.12,and the Health And Safety
ride,Section 25532(x)] All roofs shall be inspected prior to any roofing material being installed.
ED Y. On
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
crit haamdour air contaminants W defined by the Bay Area Ai,Quality Management all new materials for inspection.
District?
❑Ya Nu
I have mad the Moardsus materials requimmcna under Chapter 6.95 of ohm Califon-
n13Hcelth&Seely Code.Sections25505.25533 and 25534.1 undersand thou if the Wilding
dons not currently have a anun4 that it is my respmasibiliry an notify the occupant of the
ooq.ircm4 which, W etpdor issuanrenfacndrteateoroccupancy. Signature of Applicant Date
Come,or aur ,Cdi gcnt Dam All roof coverings to be Class"B"or better