04060070 CITY OF CUPERTINO " .s�+w.�a,. ''l `
BUILDING DIVISION PERMIT 'CONTRAC-TORtINFORMATION ar4
BUILDING ADDRESS: MACKEY CONSTRUCTION PERMIT NO.04060070
22023 BAX -EY ( T
OWNER'S NAME: PERMIT ISSUE DATE
SABA SATHYA 2593 HEBRO
lip E: SANITARY NO. CONTROL NO.
(408) 274-6799
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG 'ELECT PLUMB MECH
0 0 0
"reZp LICENSED CONTRACTOR'$DECLARATION
C 1 Mrtb affirm shat 1 areliaved un/ideJJ�rtro n o or of Chapter 9(...a a, Job Description
b with Smii a7 Dmf Divixion3ofdw Busin d Profession Code,and my license is
nay in full to deff Tj
Lieenu "Y� uc.a Sf o`I INTER. REMODEL/ADD 12 SQ. FT. FOR FIREPLACE
n�W Dart Contra< 4th �t
F�
ARCH,shall kc use DELLA ION �paG
s� 1 undcrsdlfd my plan shall M used as po rtcnrds
`LLU
Licensed Pmfcssional
gos OWNER-BUILDER DECLARATION ON 9
r. 1 hereby mand alum that 1 L exempt from the Contractors C License Law for themy /
r.p0 whichfollowingroresa pecctiun RDLruct.aer,impns ve,de nm Ca de:Any city or county
5 Q which rtwisua,pctmit m trims the alter,impmsu dcmnail t fi repair any structure $15000
a i that Inor its limmanee,also n to Me provis applicant for Conorch nniuo rile s,signed n,lemcm
< (commencing
sccgwithSrstion7 )ofDivionoltheCo asin=andPrulaw(Chap¢r9 Sq.Ft. Floor Area Valuation
x_�' (mommcncing with Section 7")of Division)of the Buxinemand Professions Cadc)ur
i 3$ that he is exempt thecefrom and Me basis far the alleged exemption.Any violnion of
Secdon 7031.5 by any applicant for a permit subjects Ne applicant o a civil penalty of
not mom Nan rive hundred dollars(5500). r 0 Occupancy Type
❑I,az owner of the property,or my employees with wages as their sole compensation,
will da the work,and the structure is not intended or offered formic(Sm.7044,Business
and Profession Coder:The Contractor's LJmme law don not apply in in o mer of Required Inspections
property,who buildsar improves thereon,and who donsuch work himself car through his
own employees,provided that such improvements art not intended oroRemd formic.It.
however.are building or improvement is said within ane year of completion,the owner.
builder will have the burden of proving that he did nm build or improve far pmyou of
sk.).
❑1,as owner of the progeny,am exclusively contracting with licensed contractors to
concoct Ne project(Sec.7014.Business and Profession Cade:)The Contrumrs U
cense law don not apply to in owner of property who builds or improves t eemon,and
who contracts for such projects with a eonmmurn(s)licenssd pursuant in the Contractors
License Isco.
-11 am exempt under Sec. .B h P C for Its reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury on of to following declaration:
hsc and will maintain a Certificate ofConsentto self-insure for WorkeriCompen-
.,,.a,as provided for by Scotian 37M of the Labor Code.for Ne perfarramm of Ne
work for which this permit is issued.
C3 1 have and will maintain Worker's Compensation Insuun¢,az requited by Section
37W of Ne lsbor Cam.rat Ne Perlarm ism of Ne work for which this permit is issued.
My W%aces Compensation Insurance artier and Policy num race: e
Cartier. 0— palieyNa,:5 6010 t
CERTIFICATEOFEKEMPITO ORKERS'
COMPENSATION IN ANI
,
Obis section need not tic completed ifthePermit is formic hundred dailus(51o0)
or leas.)
I certify that in the performance of the work for which this Permit is issued.I shall not
employ any person in my mmacrm az in become subject to the Workars Compensation
Laws of Cahromia.Date
Applicant
NOTICE TO APPLICANT:If.after making this Camino,of Exemption,you should
Income subject to the Worker's Compenselion provisions of the Labor Code,you must
.,O foMwith comply with such Pmvieinm or his retain shall k unnamed revoked.
Z CONSTRUCTION LENDING AGENCY
(—tom I hereby affirm that tem is a construction lending agency for the performance of
C the work far which this permit is issued(Sec.3097,Civ.C.)
Wes Lenders Name
.7 Z Lender's Address
(') 1 cenify That I have road this application and some that the above information is
F correct.I agree to comply with all city and county ordinances and mile laws mladng or
0 V building concoction,and hereby mthonae mpreuntionce or his city to enter upon the
�a ahovomentioned propertyree to
for indmnity an ancip es.
F
liabilities,
cove,indemnify andkith may
in
City of Cupcnstsid City
h inconstipationof o graciand g e,pcnusmit. may in anyway eccmc against said City
V z Aconsequence NDERandng of this permit
^ APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON-POINT Issued by: Dale
StLTI OlSArt ��
L/!t a (]//!(Jl.,f� Re-roofs
Si aturcof Ap IlandCWmwtor arc
HAZARDOUS MATERIALS DISCLO URE Type of Roof
Will the applicant or future building occupant store or handle havardous mamrlal
az defined by the Cupertino Municipal Codi.Chapter 9.12,and the Health and Safety
coli.section zss3z(,n
El Yes Evil. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building t use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
pp itby Me
hazardous yt,i air conuminanu rale c try Nc Bay Arca Air Quality Management all new materials for inspection.
District? •L.J//
❑Yes Nu
I have mail the harmlouseraterials requirements under Chaprer6.95of the Califon
nia Health A Safety Cndc,Sections 25505,25533 and 25534.1 understood Nat if the Wilding
donnolcuncntlyL scalers Nmitismymspomibilirywnodty upmtorthc
i n.xv,th tInmet normis eafnCeniOnmar upaney. Signature of Applicant Date
`lceceS� (o * f
Own m amtn,� =d ag=rat Date All roof coverings to be Class "B" or better