06100005 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO. 06100005
1109 PERMIT ISSUE DATE
OWNER'S NAME.
MR. NAJARYAN SANITARY NO. CONTROL NO.
JNE:
BUILDING PERMIT INFO
ARCH=CT/ENGINEER: BLDG ELECT PLUMB MECH
p LICENSED CONTRACTOR'S DECLARATION Job Description
>,i= I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Zwith Section 7000)of Division 3 of the Business and Professions Code,and my license is
=y in full force and effect. REMOVE (E) SCREEN ROOM, WATERPRROF ROOF-REROOF
? License Class Lie.8 RM
in Date Contractor (E) ROOF-ADD OFFICE r BEDRM r BATHRM r FAMILY
.J ARCHITECT'S DECLARATION
j < I understand my plans shall be used as public records
>0.0
U.y Licensed Professional
.0G OWNER-BUILDER DECLARATION
aI hereby affirm that I am exempt from the Contractor's License Law for the
cc following reason.(Section 7031.5,Business and Professions Code:Any city or county
< which requires a permit to constructalter,improve,demolish,or repair any structure
H prior to its issuance,also requires the applicant for such permit to rile a signed statement Sq.Ft.Floor Area ValoI (M 3 2 7
-?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
r F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i 3that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of AP N Number
not more than rive hundred dollars($500). 36219011 . 00
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered forsale(Sec.7044,Business Required Inspections
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 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
sale.).
),�I,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 improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
0 I am exempt under Sec. B&P C for this zeas/on
Owner w _Date ��-71�•U`b
W KER'S COM SAT N DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foi one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to bccom subject to the Workers'Compensation
Laws of California.Da
Applicant
NOTICE TO APPLICA :1f,a making this Ccrti arc f Exemption,you should
become subject to the Wori IN 11W
ker's Co pcnsation provisions of the Labnr Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z OCONSTRUCTION LENDING AGENCY
[�VI I hereby affirm that there is a construction lending agency for the performance of
a> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
0 z Lender's Address
U C 1 certify that I have read this application and state that the above information is
w correct.I agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorize representatives of this city to enter upon the
W ahovc-mentioned property for inspection purposes.
11. (We)agree to save,indemnify and keep harmless the City of Cupertino against
t) liabilities,judgments,costs and expenses which may in any way accrue against said City j
U Z in consequence of the granting of this permit. Date
C�
O• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SO REGULATI NS.
1A 41A4 on, o,m U6 Re-roofs
Signaturepplican con for Dam Type Of Roof
HAZA OU ATERIALS DISCLOSURE yP
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cede,Section 25532(a) All roofs shall be inspected prior to any roofing material being installed.
0 Yes {Q No
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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Dlslnct?
❑Yes [/No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safcty Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant.that it is my responsibility to notify the occupant of the
requirepte nts which must met prior to issuance of a Certificate of Occupancy. Signature Of Applicant
Date
Y -4 101 311 UG All roof coverings to be Class"B" or better
Owner or orized agent Date