04030221CITY OF COPERTINO
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BRMI
BUILDING DIVISION PET
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BUILDING ADDRESS:
WASFI HUZAYYAN
IFRMIINO-04 03 022 1
195 0
OWNER'S NAME:
PERMIT ISSUE DATE
WASFI HUZAYYAN
SANITARY NO. CONTROL NO.
ARCHrrTCVENGINEER:
BUILDING PERMIT INFO
PL= MECH
=1 0
LICENSED CONTRACTOR'S DECLARATION
O eBCrl p UOn
I hereby AM. that I em licensed under provision, of Chapter 9 (comwndng
wit Suction 7") of DWWon 3 of Business and P owsmom Code, atW my license le
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(.11 form Class erten.
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Dau Command,
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ARCHI'E ECI'S DECLARATION
1 understand my plans mail he used an public records
1
Licensed Proricshereby
OWNER -BUILDER DECLARATION
AM
I hereby.(Sero that 11. exempt law for the
m We COmons
Co e: Any c
following reason. Permian 703 1.5,B, aineurod Profession, Code: Any city
s
which pagWrs a permit In coronet, alar- Improve, demolish, par wash any stcounty
t, umment20000
prior m its issuance. pursuant rlw aquina tM vision of for ash permit m file am Lad atammnt
aiat the Connector's Licear
Sq. Ft. Floor Area
`V"luation
and mionCltapur9
ofDivisio 3due
mancin witS70
Pmt ngwit Section7a011) Crede) of
ofalege exempton.
Myons
ndthaDivision3
Wt he u sempt UOere(rom and dm bu4 for due alleged exemption. My viOlellon of
he is
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MAI—r——0
Occupancy Type
ion 7031.5 byAny
ndndlicalanu a per. it subjects the Applicant n a civil penalty of
newt dun Eve
❑ 1, u owner of to property. u my employees with wager as their sole compensation.
Required Inspections
will do the work, and to suuctupa is not intended or offered for Ne (Sec. 7044, Business
and Profession, Code: The Conuacror's Ldcetu Lew does at apply W an owner of
pmpeny, who bui1N or improves due m on, ted who doea such wok himself or trough his
awn employes. provided that such Improwmn, am Autimmnded aro@red for We. It,
however, the building or Improvement is sold within one your ofcompledon, the many.
Wilder will have tiw burden of proving that he did not build or Improv for purpose of
Am ).
1. u war of W progeny, am exclusively connecting with licensednnvsemn to
c met due projn Dec. 1060, Business anal Profession, Code) M ContractorsU-
aMe law dote not apply W in owner of property who builds or improves (hereon, rod
w'ed Pan to CnuM1
for projects with a conlna W H+) IlaMnum actO
conactsn
Cleave law.
❑ I unexemptunder See .B@PCfardtbreuon
A�.G.2 v]._' ,AYV[. i 01 Dow
ORKERS COMPENSATION LARATION
I hereby afnm under penalty of perjury on, of to following declustdou:
hive and will maintain • Carillon ofConsem w self-inxure for Workeel Compcn.
moria:, u provided fm by Section 37x0 of due labor Code, fee to performnce of the
work for which this permit ls issued.
❑ 1 have end will maintain Worker's Compenudon Insurance, u required by Section
3700 of the labor Code. few & performance of the work for which tis permit is issued.
My WeCompensation Insurance carrier and Policy number An:
Carder. Polity No.:
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssection need not beampleted If the permit is faorohundmdd00en (SI00)
or kit)
1 certify that in the performance of the work IN which tis permit is Issued 1 tell not
employ any parson in my meaner an as W become subject n dM WOIkn+' Compensation
Laws of Califomu. Dau
Applicant
NOTICE TO APPLICANT: If, after making ails Ceninam of Exemption. you should
hecome subject W due Worker's COmpcaation provisions of the labor Cade. you mum
forthwith comply with such provisoms or this peul,shall be deemed nvokcd.
CONSTRUCTION LENDING AGENCY
—
I hereby oflirm duet ten le a.onammednn hntng agenry for the pufurreana of
to work for which this permit Is issued (Sec. 3(191, Civ. C.)
Lundeen Name
Lender'sAddrau
1 ce t ly that I haw read thin application and sum duo due show Informaim Is
'
comm 1 a&= W comply with all city and county ordinances and suss leve painting te
building construction. and hereby Authorize papnunutiw+Of this City to Anter Open the
ahow-mentioned property for Inspection purposes
(We) agree W nw, indemnify and keep harmlw the City Of Cupertino against
Iiabllitia, judgments, cot, and expenses which may in Any way acerae against mid City
in conngonee of to growing of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
-
Qy
rAp n men nnor we
SI711
HAZARDOUS MATERIALS DISCLOSURE
we applicant or future building asap e, stow or handle ha? -No -,-material
as depend by to Cupertino Municipal Code, Chapter 9.11, and the Health and Safety
Code.0Section, z5s3z(a)+ l
❑Yu AR No
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the epplicnt or fu\Wro building occupant use equlpmnt or devices which
hvardnu aircmumiann u definc0 by due B+y Arta Air QueliOy Mmagement
all new materials for inspection.
❑Yee peau
1haw mad duehnaWommawrdalswquimmcnts underChapter6.95oftheCalifonkal"SefmyCOdc,Sttdaa15Nj5,25533nd7S536.luWmn
ftifthe Wilding
not currently baw A unam. Chat it, my reponsibility to Andfy de oaupn0 of Ne
which must be met prior u issuance of a Ccnifica Of(xglguoa�
Signature of Applicant Date
�DaW)
All roof coverings to be Class "B" or better
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