02070024 CIBUILDINGON
UPERNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10071 ORANGE AVE DOYLE CUMMINGS PLUMBING 02070024
OWNER'S NAME: APPLICATIONS7}J3B DAT" '
FATEMEH GHOLOMREZA 14311 BUCKNER DR 07/ 0372002
PHONE: 4089234221 SANITARY NO. CONTROL NO.
p-,.
OO ARCHITECTfENGINEEK: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
L _J L "I
h i LICENSED CONT'RACTOR'S DECLARATION
I hereby arum mai 1 am licensed under pnrcisions of Chapter 9(commencing CLEAN OUT lob Description
{NFu withSmion)IKp)af Division Jufnhe Bminca Professions Code.antl my license
-a is in full ffarce�and<IT
8
C z a License L�yy: tP Lid. S S
:O y u I c t `t cars n n
i S v ARCHITECT Drs ATION s
' O 1 understand my plain,hall be used as public rtcoNs
it
i i p O Licensed Pntlearionnl
I LL Oat I am exempt
m the ontr10N
1 hacby affirm that 1 1. cwmpl from the Contractor's e:License Law for IM1e
which
mason(Swoon 703L6 Business mp ve.de o demolish,
Codc:Any city'or county $1000
Owh h 9 su pe m t I Construct, h r,improve.dcmel sM1 p' )structure
a3. Prot its issuance,also q_ th 'Pions o the Coforsucntractor
11signed (amainthat he dingwdpnuasl Thep in3ofthemcmr Le (Chapteroe) •lr8d'2�L�4�a . : i k" ...__. .... - Valuation
or thmim
(Commending exempt with scat on 91100)or Deviators J of ec Bumtm d P fissions CMe7 t : 'r; - ,• , � {
of mat fie is 31.5bInert from and Inc basin for the subjects
th tl d Beano to Any lPenalty
ofSection than by any dreddmnfor(,permit sonjecta the applicant maevil Penalty 106` K4t42 & WATER - Occupancy YP
ar not more man fine nanamd dnnar, sSW. PN Occu ani Type
❑I.as owner of the property.or my employers with wace,as thou.)e compensation. 202 — UNDERFLOOR PL BING
will ne he work:and the.wewhe is nal intendedlisLi en a Law for snot app( taus. 3 01 — ROUGH PI -
Bulido and Pm.-.Cd the
traction,
Theis do,sLicense Law tines not(Secy man INfnspec[ions '
caner of property Who builds or improves Thereon,and who does such work himself 3 0 2 - TUB & OR HOWER
oimmiii his own employee,,provided thin such imptn,emcee arc not intended or
feeed for sale.If.however,the building or imprdvemem in,old when dad .Of 502 — " FINAL PLUMBING ENERGY"
inmpletion,the ox ner-h B1dc ,will he,.the burden fronting that he did not build or
mprove' purpnacn e 506 — GAS TEST
_ o L�r owner of the vroPmr:adt ucm;i:thy eomraning wGn rre�aed ecm ,a I�r(to 507 FINAL PLUMBING ._. .. ...... . ._ . . . .. _
construct the project(Sec.74W.Business and Professions Code:)The Contractor's
License Law does ani apply to an owner of propeny who builds or improves thereon.
_I and oho contracts for such Pmjwls with a comamorg)licensed pursuant tu.dte --- ...
Contractor's License Low. �OC10 ft
❑I am exempt under sec .B&PC fortis reason
Owner Date
WORKER'S COMPENSATION DECLARATION AUG 0 7 2002
I hereby affirm under penalty of Perjury one of lith following declarations: ! C G
1 have and will maintain a Cenificam of Consent to self insum for Worker's SUR
D'��
Compensation, u provided L
lot by Section 37W of the Labor Codes for the
performance of the work for which this penton is issued,
❑1 have and will maintain Worker's Compensation Insvmnco,as required by Sodium
37W of the labor Code:for the pcfifoermac.of the work for which this permit m
issued.My Worker's Compemafimn Insurance dartyr aM Policy number arc: ,.
G :S�farr, Fug t Pahey . lsla9lobo aooa
CERTIFICATION OF EXEMPT ON FROMWORKERS'1
COMPENSATION INSURANCE'' .t s
-'(This section nadd not be completed if the permit is for one hundred dollars
($1 00)or loss.)
I cedif than in the rfurmance of the work for which - ,
y' pe ien This ct ad t e issued.( - - -
shall nal employ any person in any manner so as to become subject m IM1e Workeri
Comnlawn of Culifnrnin.'Da¢
Applicant
NOTICE TO APPLICANT.If,after makingthis Certificate o of Exemption.you should
becomesubject m the such
Colons or this
previsions of the Labor Code,you most
z O forthwith comply with ouch pmvi,inns or thin permit shall be Deemed invoked
i s i CONSTRUCTION LENDING AGENCY
1 work
which this
is s coned(Sed. lending agency for me peRomlance
Lf the work me which This permit i,issued(Sec.31397,Civ.CJ
.7 z Lender's Addres.i . . ,
i
V' 1 unify Thar 1 have raid this applicalon and slate that the above information is
fL'F correct.I agree to comply with all tiny and county ordinances and state laws relating
to building constrvnion.and hereby authorize representatives of thin city m enter upon
the above-mentioned properly for inspection purposes
FF•1 ai (We)agree to sine.indemnify and kttp handi the City of Cupersino against
(n liabilities.judgments,costs and expenses which may in any way(cane against,said
V City in consequence of the granting of this permit r;
AOPLICA�FGULAF10p'UNDERSTANDS AND WILL COMPLY N'jT_HALI1 N�O.M13''P�?T Issued by: D to
A �J°1
Signature of ApplicanUCommcmr ,Dam Re-roofs
-' HAZARDOUS MATF.NIALS DISCLOSURE '
1 Wt11•ec aPP1 w Ior f care tunking occupon mom or handle hasamous material -Type of Roof
as derncA by the Capers M I Cad Ch pan 9.12.and the Health and Safny
Code Seel on 25532( 1 ' . z s
All roofs shallbe.inspected"prior to any,. roofing,material being"installed._
Will the ppl e T defulum buildinfloccupant q p t o do h«e which If a roof is installed without first obtaining an inspection, I agree to remove
emit h ma dou. it contaminantsd rimed bye Bay Arc A Quality Management
District? all new materials for inspection. Applicant understands and will comply with
❑v ❑ all non-point source regulations.
I
have
mail.lhe hazardous mairriah rcgmremena under Chapter 695 of the
California HFelth&Safety Code.Sections 25505.25533 and 25534.1 understand the,
if the building docs not curmatly have a torn(.mal it is my responsibility to notify the
occupant of the requirements,x hich must be met prior to issuance of a Cenificam of
10,
°0°"`y' Signature of Applicant Date
Owner,rnmm�rired agent pole All roof coverings to be Class "B" or better
- OFFICE' '