07030161 CITY OF CUPERTINO
BUILDING DIVISION PERMITt�1 'RE� fi? I� }LMTIO �
BUILDJNfjtrpMEBANON DR TBD — ERMIT TO BE DETERMINED P07030161
OwNER'S NAM/E: PERMIT ISSUE DATE
SRIDHAR OBILISETTY 05/04/2007
PHuNE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i 0 p LICENSED CONTRACTOR'S DECLARATION
W !hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
?z O with Section 7000)of Division 3 of the Business and Professions Code,and my license is HOUSE L EMO AND POOL DEMO IN REAR OF HOUSE.
y in full force and effect.
j r2 4 License Class Lic.n
-t„m Date Contractor
ARCHITECTS DECLARATION
7 oC< I understand my plans shall be used as public records
)yU
u.y Licensed Professional
H< OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
`<m P which requires a permit to construct,alter,improve,demolish,or repair any structure
z} prior to its issuance,also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q.Ft.Floor Area Valuation
rI=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $4500
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant 10 a civil penalty of �jj�� Number Occupancy Type
not more than five hundred dollars($500). 3 4 2 14 0 0 8 A?W
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale
W,as owner of the property,am exclusively contracting with licensed contractors to
I
trust the project(Sec.7044,Business and Professions Code:)The Contractor's Li•
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projecs with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt urRhs( e ,B&P C for
Date
bbi
S COMPENSA71ON DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person' an anncrsoasto kcrs'Compensation
Laws o
f Califo '
Applicant
NOTICE TO A If,after making this Certificate of Exemption,you should
become subject to orkcr's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
(~i ice. 1 hereby affirm that there is a construction lending agency for the performance of
Qui > the work for which this permit is issued(See.3097,Civ.C.)
aQ Lenders Name
Z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
►^ correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
a ahove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
fA liabilities,judgments,costs and expenses which may in any way accrue against said City �y
V Z in consequence of the granting of this permit. Date �-'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
Re-roofs
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
te,Section 25532(a)? �.,� All roofs:,hall be inspected prior to any roofing material being installed.
❑Yes W^''°
Will the applicant or future building occupant use equipment or devices which If a roof i installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new m iterials for inspection.
District?
❑Yes
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety C ,Sections 25505,25533 and 25534.1 understand that if the building
does not currenAy ha tenant that it is my responsibility to notify the occupant of the
rcyuircmcn m be metprior toissuance ofaCcrtifica ofoccupancy. Signature of Applicant Date
�� All roof coverings to be Class"B"or better
Owner or authadaitZgent Date'