07070257 CITY OF CUPERTINO �������� ���}�,�j ':
BUILDING DIVISION PERMIT
PERMIT NO.
BUILD � x �� 4,o 4 ES GASCOIGNE DR REGRID FOWER 07070257 •
.S
pgRMIT LSSUE DATE
OWNER'S NAME: 1 � � 5 2 � � 7
KHOSROW KHAGHANI 1624 DEIL AVE
SANITARY NO. CONTROL NO.
, "E: (408)92�-0811
BU(LDING PERMITINFO
ARCHITEC'C/ENGINEER: BLDG EI.ECT PLUMB MECH
� � � �
� Q � LICENSED CONTRAC'fOECS DECLARA7'ION JOU DCSCT1pL1011
� V� I hcrcby afGrm �hat I am limnscd undcr provisions oC Chaptcr 9(commencing
; Z� wiih Sccrion 700U) ot Division 3 of thc Business and Profcssiuns Codc. and y Iiccnsc is IN STALL S OLAR ( PV � SY STEM ON A RE S I DENT I AL 1��
>> y in full Corce and cCCect
� v� z Liccnsc Class ��• *
� p Dam� Contractor
; �" � ' AR HITECI'S DECLA ON
i a Q 1 undcrstand my plans shall bc uud as public recor�Ls
)yV
� w y Liccnscd Pnifcssional
: Q a OW NER-BUILDER DECLARATION
�<� hcrcby atTirtn tha� t am cxcmp� Crom ihc Comractors Liccnsc Law (ar �hc
p O Collowing rcuon. (Scction 7031.5, Business and Pro[cssioos Catc: Any city or county
� m� which requircs a pcimit to conswc4 altcr. improve. dcmalish �� ��v� �y ���� , Valuation
�^ y p ri o r t o i � s i ss u a n c e. a l w r c quires U�c a p plicant foc such pertn�t �a fik a signcd statcmcnt �' , Ft. F�OOP ALeS
-?< �hat hc is IiccnscJ pursuant to thc provisions o( ihc Convac�ar's L iixnsc 1 aw ( C ha P t c r 9 `� q $ 2 3 0 0 0
Y F�(commencing with Scction 7000) of Division 3 of ihc Busincss and Profcssions Codc) or
i�,,, �a� he is ��cempl thcccfram and We basis for the allcged exemption. Any violuion o[ Number Occupancy Type
Section 7031.5 by a�ry applicant Cor a permit subjects the applicant to a civil pcna►cy of 3 7 5 2 3 01) ��
no( morc � han 6ve hun dred dollars (5500).
� I, az ow�r oC tl�e property. or my employces with wages u the'v solc comperuaGon,
willdolhework,and�hesuucWmisnoeintendcdoratfered[orsale(Sec•7044•B'�^�ss Required Inspections
and professions Code; 11u Conuutors License L.aw dacs nat apply to an awur ot
propeny who builds or improves thercon, and wha does such work himself ar ttwugh his
own employcciss. provided cha� such improvemen�s are not in�ended or oRered for sala It,
however, the building or improvement is sold within o� year of completioo, die owur-
builder will have the burden oC pmving that Ix did not 6uild or imprmc far parynx of
sale.).
0 1, as oaner of the property, am eacclusively conuaeting wi�h Gttnsed rnnuxtors w
wnsuuct the project (Sec. 7044. Business and Pro[essions Code:) 77K Conuaccars Li-
who onvacu of r such p with coni li to the�Convx�ars
�'�"� ��"' , 8& P C for �his rcason
❑ I am ezempt under Sec.
Ownu Date _ . °
WORKERS COMPENSAI'ION DECLARATION
l hereby afficm under penalty of perjury onc of the Collowing declarations
❑ i hsve and will mainiain a Cenificatc ot Conscnt w selC-insure (ar Worke�s Campen-
sation, as providcd for by Secdon 3700 of the Labor Code. for �he performance ef �he
work tor which this permit is issucd.
❑ I havc and will maintain Workcr's Compensation lnsurance. as caluircd hy Scction ,
3700 a[ the Labor Code. Cor the pertarmance of ihe work fw which �his pe�mit is issued.
My Wor Cqmpens tiQn lnsurance carticr and Poliry M � ���/�
Cartie Poliry No. r�
ERTIFICATE OF EXEMPTlON FROM WORKERS'
COMPENSATION INSURANCE
(I7iit scctian nccd not bc completcd if the permit is [or anc hundred dallars (E100) •
or Icss.)
I ceniCy that in thc performancc af �hc work for which Wis pertnit is issucd• I shal� not
employ anp person in any mannc� so as to bccome subjcct �o lhe Workccs' Compensatiun
Laws of Califomia. Datc
Applicant
NOTICE TO APPLICAM: If, aftcr making U�is CcniGca�e of ExcmpGon, you should
bccome subjcct a thc Workcr's Compcnsation provisions o[ Wc La6or Codc, you musc
�� foMwith comply with such pmvisions or this pccmit shall bc dccmcd revokcd.
Z � CONSTRUCI'lON LENDING AGENCY .
F ►�-i I hece6y alCirtn Wat there is a construction knding agency for the perCormance of
�„ � ihc wurk for which this permi� is iuued (Sec. 3097, Civ. C.)
LLa Q L.cndcr's Namc
� z Lcnder's Address
i certify �hat I havc read this application and sia�e ihat �he above intortnatiun is
�� correct. I agrce to comply with all city and county onlinances and sute laws relaung to
� U building conswction, and hcreby authori�e reprcsentativcs oC this ci�y �o cntcr upon thc
abovc-mcntioncd property for inspccuon purFwses.
�" a (We) agrce to save, indcm�i(y and kecp harmlcss Ihe Ciry of Cuperlino against
�� liabiliries, judgmcn�s, costs and expcnses which may in any way accruc against said City D3I0 `� �
U z in consequcnce oC thc granting ot ihis perm�4
� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b �:
SOU REGULATIO
,��--���, ��bC7 /����� Re-roof: ��
SignaturcoCApplicanUConuactor �� T of Roof
HAZARDOUS MATERIALS DISCI.OSURE YPe
Wil( thc applicant or futwc building acupant storc or handle Aa•rardous matcrtal
u dcfincd 6y the Cupenino Municipat Codc. Chapler 9.12. and �he Hcal�h and Sa[ety
c«k Scction 25532(a)? All roof � shall be inspected prior to any roofing material being installe .
❑v°5 �° If a roof is installed without first obtaining an inspection, I agree to remove -
Wi11 the applicant or Cuwrc building occupant use eyuipment or Jevices ahich
cmi� ha•rardous air contaminan�s as dcfincd by the Bay Ama Air Qualiry Mana6cment alt new materials for inspecxion.
Dsstrici? •
❑Ycs ��
I havc rcad ihe ha�ardous matcrials requircmcnL� undcr Chaptcr 6.95 of ihc Califo�-
nia Hcalih & Safcty Codc, Sections 25505, 25533 and 25534.1 undcrs�and that i(U+� build'"B
docs nat curtently havc a tcnant, that it is mY resPans�bility w noul'y ihe occuPani �� th� Date
rcyvircm �� h���orwi uanuotaCcrtil'icate�� c�cy � Signatu �e of Applicant
> All roof coverings to be Class "B" or better
O�Jncr o �horizcd agcn� F Datc