04100156 (2)CITY OF CUPERTINO -" "—' '
BUILDING DIVISION PERT "'
�CO�NTRACTORANF&MATION 4,
BUILDING ADDRESS: -
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FERMrr No0 410 015 6
7564 DE FOE DR
IER'S NAME:
PERMIT ISSUE DATE
AJAY ATHAVALE
PHONE:
SANITARY NO. CONTROL NO.
ARCHRECT/ENGINEER: - .. ..
BUILDING PERMIT INFO `
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I Mo by affirm Ion 1 am licensed under provisions of Chapter 9 (commencing
with Schon 70f10) of Division 3 of the Business and Pmeaskms Code, and my license is
in full fame still effect
Liceme ClassLie. a
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ADD 781 SQ-.FT. (BEDRM/STUDY) REMODEL—_ - - -- --- -
DO_¢ Contactor
ARCHITECT'S DECLARATION
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1 understand my plans shall M used u public remods
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Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby a?ren that I am exempt form the Communes License Law for the-
following reason. (Seedon 7W I.S. Business and Professions Code: Any city or county-
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which requires a Food, to concomm, alar, improve. demmish, no.,.I, any M.M.
prior to its issuance. also requires tot applicant for such permit to rile a signed statement
that bcislicensed puauantto the provisions of the se Comment's License: Law (Chapter 9
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Sq. Ft. Floor Area
- Valuation
(commencing with Section 70M) of Divition 3 of the Business and Professions CMe) or
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that he is exempt mc¢from and the basis for the alleged exemption. Any vlolmmm of
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Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
not moa dmve fihundred dollars (M).
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I, as awes of the propeny.mmy employee¢ wiN wgm mtheir sole compcnwton,
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- - - -- '-Required In peCLlonsy-, -
will eco thew.rk,mdthes,ucmreismin umendedmoffered forsalc(So,. 7064. Business
and Proftasa oro Code: The Connecticut's Limme Law doe] ml apply le an owner of
propcnywhobuildaeumprovumercon,andwhodoanch work himself., through his
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Own employers, provided that such improvements are not intended oroRead forsak. It.
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however, me building or improvement is sold within one year of compledon, me nwncr-
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Ming
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Wilder will Move the bumen of proving that he did nut build or improve for purpose of
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salt.).
eA owner of the property, am exclusively contracting with licensed contractors to
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c.Q.1 the project (See. 7046, Business and Professions Code) The Conlracmr's Li-
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come law dors not apply loan ownu of property wM builds or improms thereon, and-
whoconmetsfor such projects with. eonvact.,A) Iicemed pursuant to me C.mneer's
License law.
D 1Am axcm pt under See. .B&PC for Nis rtamn
cr Data
WORKER'S COMPENSATION DECLARATION
1 hereby, a0irm under penalty of perjury ane of the following dalantions:
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IbanandwillmaintainaCcrdficateofConscnuoself-insure fur Workers Comism.-
snion, . provided for by Sudon 3700 of the labor Code, for On performance of the
work for which this permit is issued. -
D 1 have and will maintain Workers Compensation Insuanct. As mquimd by Section
3700 of the labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance artier and Policy number Am:
Came'.. Poli, No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not oc mirpleled if the permit is for.. hundred dollars (SIM)
or Ices.)
1 certify con in thperfmmmce of the work for which this Permit i] issued, 1 shall not
employ any perm m y scum beeOflle subject to the
Law ] Of Ca
APPlicant
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N ETO APPLICANT-. If. after making this CeniBcatc of Escmption�uW
e subject ro the Worker Compensation provisions of the labor Code, you most
thwith m.,L, with such pmvni.ns or this Permit shall be deemed revoked.
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CONSTRUCTION LENDING AGENCY
Ihereby M. that thea isamnstructinn lendinpgemy for the perfurmanu of
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' to work for which this Femur is issued (Sec. 3097, Civ. C.)
Lenders Name_--
L cedtes Add.
j 1 certify that 1 ban read this application and suis that the above information is
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' c.mect.1agree to comply with all city and county eminences and sou laws !elatingm
ibuilding eonmmetion, and hereby auth.me mprescnadves ofeis city us enter upon the
l above-mentioned property rot impeetion purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j Iimilitiu,judgments.cos, And cxpcmm which may in my way accrue against aid City
V71691110
in consequnce of me granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY W�iLNO-PO1M'
Issuedby: Date
SOURCE NS.
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Re-roofs -
Type of Roof -
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I Signs= Applicant/Contractor Dam
-HAZARDOUS MATERIALS DISCLOSURE
Will In.applicant or future building mcupmt store or handle humdous material
defined by the Cupertino Mun ei I Code. Chapter 9.12, and the Hcmh and Safety
k. Section 25532(a)?
Dy. ll7'14u
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 me applicant or future building occupant use equipment m devices which
emit eavardous air contaminants a droned by Ne Bay Area Air Quality Management
all new materials for inspection.
District? `
Dyes 0.
1 have real the havamno]makrials Mc Me m ma under Chap¢, 695 of t e Califor-
nia Health& Safety Com. Sauons 25505, 25533 md25534.1 undersand Nat if the building
does not commty bac a tenant, Main is my M.Ponsibi ty in notily toe oecupmt of the
uimmcn,wk m met Prior m issuance of. Rc:k of Oce
Signature of Applicant Dale
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All roof coverings to be Class "B" or better l/
caner or.ria�d agent Dale