07080274 CITY OF CUPERTINO f � r
BUILDING DIVISION PERMIT �+�������
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PERMIT NO.
BUfL C ���� o � xES �EMPSTER AVE TBD - TO BE DETERMINED 0 7 0 8 0 2 7 4 .
PERMIT ISSUE DATE
OWNER'S NAME:
SUDHA PENDYALA 09/28/2007
SANTTARY NO. CONTROL NO.
�NE:
BU(LDINC PERMITINFO
ARCHITECC/ENGiNEER: BLDG ELECT PLUMB MECH
� 0 � �
i p a LICENSED CONTRACTOR'S DECLARATION JOU DCSCTlpt1011
'�� I hcreby aCGrm that I am liccnscd unckr provisions of Chaptcr 9(commcncing
'; Z� wiU� Section 7d00) of Division 3 of Ihc Busincss and Profcssiuns Codc and my liccnse is ADD 2 6 � ' BEDRM , BATHRM- REMODEL 2 � � ' C ONVERT ( E�
� j N in [uu focce and cc[ec� � q, S��� STUDY T� BEDROOM # 4
� v� Z Licensc Class L�. �
p Da�c Conuacwr
: �"' � ARCHITECI'S DECLARATION
i a Q 1 undcrs�and my plans shall bc uscd u public recordc
)yU
� w y Liccnsed Prufcssional
� � a OWNER-BUILDER DECLARA'CION
j a� 1 hcrchy alTirm lhat I am cxcmpt Crom ihc Conlractor's Liccnsc Law far thc
. p O following rcazon. (Scction 7U31.5, Busincss and Profcs�inns Calc: Any city or county
�,°, �i which rcquires a pertnit to cnnsuuc4 altcr, improve, dcmolish, or repair any swcture
�" y prior w i�s issuance, also requires ihe applicani Cor such pertnit to file a signeJ sia�men� � q , Ft. Floor Area Valuation
"?'a �hat hc is liccnscd pursuanl to thc provisions o( thc Conlractur's Liccnu Law (Chaptcr 9 $ 4 6 3 4 5
� t �(commencing with Section 7000) af Division 3 of !he Business �nd Profcssians Code) or '
L�� �hat he is e�cempt thcrctrom and Ihe basis for ihe allcgcd exemption. Any violation ot Oeeupaney Type
Secdon 7031.5 by arry applicant for a permit subjecu tho applicant to a civil penalty ot 3 2 6 4 8 0 2%� Number
not more �han fivc hundred dollars (5500).
❑ I, as owncr oC the property, or my employces with wages az their solc compensation,
wi11 do the wark, and the suuctum is not intendcd or oftered torsak (Sec. 7044. Business Required Inspections
and ProCessions Code: "Ihe Conuactor's License Law docs not apply w an owner of
propeny who builds or improves �hercon, and who dces such wo�lc himsel[ or Uuough 6is
own emplayccs. providcd Uiat such improvemen�s are not iNended or oftered (or sale. lf.
however, the building or improvement is sold within one year oC complctian, the owner-
builder will have the bmden of proving that he did not build or improvc for puryose of
salc.).
�QI, u owner o( the property, am exclusively conuacting wi�h licensed convactors m
tonstruct die pcoject (Sec. 7044. Business and Professians Cade:)'Che ConUactofs Li-
ccnse [aw dacs not apply to an owner of proputy who bailds or improves Ihereon, and ,
who conuacts Cor such projects with a convactor(s) licensed pursuant to Ihe Contractors
License Law.
❑ I am aempt under Sec . e& P C tor this n
Owner Date � 7 � " _ _ _,-
WORKER'S CO PEN ON DECLARATION '
I hereby affirm under penalty of perjury one of �he fallowing declazations:
�/ 0 I hsae and will maintain a CcrtiGcate of Consent to self-insurc (or Workc�s Compen-
sation, as provided for by Section 3700 af the Labor Cod0. for the pedormancc of thc
work for which �his pr.rtnit is issucd.
❑[ havc and will maintain Worker's Compensation Insurance, u rcquired by Scction .
3700 of thc Labor Code. Cor �hc performancc of �he work for which this permit is issued.
My Worke�s Compensation Insurance cartier and Poliry number are:
Cartier. Policy Na.:
CER7'IFICATE OF EXEMP'lTON FROM WORKERS' .
COMPENSATION INSURANCE
(7]�is scctian necd not be complctcJ if the pe[mit is for onc hundced dotlars (S I00) ,
or Icss.)
I ccnify ihxt in Wc performancc af ihc wo k for which �his pertnii is issucd, I shall not
employ any person in any manncr so c c jcct to Uie Workcrs' CompensaGon
Laws o( Califomia Datc
Applicanl
N017CE TO APPLICAM: If, afur making this Cc iCcatc of Excmption, you shauld
become subjcct a lhc Workcr's Compcnsation provisions of ihe Lal�or Codc, you must
� O forthwi�h comply with such pmvisions or this pccmit shall bc dccmcd rcvokcd.
z "' CONSfRUCT10N (.ENDING AGENCY
F r � I hcrcby a[I'irm that thcre is a conswction knding agcncy Cor thc performance oC �
a i✓ ihe wurk far which this permit is issued (Scc. 3097. Civ. CJ ,
(L� A Lendcr's Namc
� z Lenders Address
U � ► certifY �hat I havc read this application and s�aic that ihc ahovc informatiun is
�� corrcct. 1 agrce to camply wiih all city and county orelinances and sute laws relaiing lo
� U building conswction, and hercby authori�e rcprescntaiivcs of ihis city to rntcr upon thc
� W abovc-mcntiuncd pro{xny (or inspccuon purposes.
a (Wc) agree to save, indcmnify and kecp harmless ihc City o( Cupertino against
�� liabilitiu, judgmcnls, cos�s and expcnscs which may in any way acccuc againsl said City
(� z in consequence oC tAc granting of this permit. Date
� APPLICANT UNDERSTANDS AND WI OMPLY WITH ALL NON-P INT Issued by: �
SOURCE REGULATIONS.
` ( V 5 �� Re-roofs /� /
Signawreo(ApplicandConuactor ��� T e of Roof � `�
HAZARDOUS MATERIALS DISCLOSURE YP
�II �he applicant or (uturc building occupant store or handlc ha•rardous maicrial
az dcfincd by the Cupertino Municipal Codc. Chap�cr 9.12, and du Hcalth and Safety
c«� ,Section25532(a)? All roofs �hall be inspected prior to any roofing material being installed.
❑ Y� �p •
I If a roof i� installed without first obtaining an inspection, I agree to remove
wll thc applicant or fuwre building occupant usc cquipmcnt or dcvices which
emit harardous air contaminan�s u dcGncd by the Bay Arca Air Quality Managcmcm all new m aterials for inspec*ion.
DISI[ICI�
❑Ycs ��No
1 havc rcad the ha�ardous matcrials requismcn�t un�icr Chap�cr6.95 of tM Cali(or-
nia Hcalth& SafctyCodc, Scctiortc 25505.25533 and 25534. I undcrst�nd thaiiCihc building
docs not curtcntly have a tc ant, �hat it u my responsibiliry to notify thc axupant n( thc
rcquiremcn�s which mpsi�met �or to issuance o[ a Ccrtifica�c o� �u — g ignature of Appl icant Date
r �`� ►U`� All roof coverings to be Class "B" or better
Owner or authori'.ed egen� Daie ---