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05040040z C — �z UC Li. H OU U 1 CITY OF CUPERTINO BUILDING DIVISION PER ���� INF(RML1 �• BUILDING ADDRESS: HAMI D ABTAHI PERMIT NGO 5 0 4 0 0 4 0 10661 JOHENSEN AVE OWNER'S NAME: PERMIT 1.4SUE DATE 10660 JOHENSEN AVE PHONE: t SANITARY NO- CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH Q LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full forge and effect. ADD 5 61 ' (B E D RM / L I V 4 2 0 ' — GARAG E License Class Lic. p .) ./ Date Contractor _ ARCHr1ECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractors License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires lne applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of 7,kPWJQdaZclQ 0 Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty -of not more than five hundred dollars ($500). ❑ 1, as owner of the property, or my employees with wages as their sole compensadua, _ Required Inspections will do the work, and the structure is not intended or offered for sale (Sec.7044,Businisa and Professions Code: The Contractor's License Law does not apply to an owner of ns q p 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 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 sale j 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li- cense Law docs not apply to an owner of property who builds or improves thereon, and , who contracts for such projects with a contracior(s) licensed pursuant to the Contractors License Law. ❑ 1 am exempt under Sec. , B & P C for this reason .. Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following !declarations: ❑ 1 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. QiAa yo My Worker's Compensation Insurance carrier and Policy number are: ' Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is i, uc , I shall not employ any person in any manner so as to become subs -'est to the Worke ' C mjrensauon Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Ccrtiticate, of Exemption, y u should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed mvoked- CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lenders Name . Lender's Address 1 certify that I have mad this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authod7z representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) indemnify agree to save, and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. DERSTANDS AND WILL COMPLY WITH ALL NON -POINT APPLILREG Issued by: Date SOU LAT� S,' G©j Re-roofsi a(uicanll ontractor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle haiardous material as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety Code, Section 25532(a)? �� ❑Ycs All roofs shall be inspected prior to any roofing material being installed. Will If a roof is installed without first obtaining an inspection, I agree to remove the applicant or future building occupant use equipment or devices which emit hazardous air contamioamis as defined by the Bay Area Air Quality Management all: new materials for inspection. District. ❑ Yes LQN0 1 have mad the hazardous materials requirements under Chapter 6.95 of the Cal ifor- niaHealth&Safety Code, Seetons25505,25533 and 25534.1understandlhatifthebuilding / Date All roof coverings to he Class "R" Or hPfter