08060057 CITY OF CUPERTINO e9'
BUILDING DIVISION PERMIT eCCINTRAC(fOR INk'Ui2M' ' '10;5'
BUILDINO ADDRESS: PERMITNO.
10424 DEMPSTER AVE TBD — TO BE DETERMINED 08060057
NETS NAME: PERMIT ISSUE DATE
ALAGARATNAM, MANIAM 10/09/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
fop LICENSED CONfRACIVR'S DECLARATION
mii hemby affirm WI l am Ikcmea under provision of Chapter 9(commencing Job Description
< with Section7O10)ofDiviaionSoftheBusircsnandProfetimuCode,andmyl(cmLeb ADD (306SQ) ATTCHD PATIO CVR TO REAR SFDWL
^�N in full to=that affect. �Q 7
j ? Lkens Chat, —Lk
m /5 .N L
F Da /aJ 22- t-' Conley 1
c� T ACTS DECLXRA71ON
2 1 undrnund my p Wu a1Wl be axd u public rttondo
g G I; Licensed Professional -
`h3 OWNER-BUILDER DECLARATION
ii F I hereby alarm Nn 1 am uempt from the Contractors Uconm Law for Ire
O O following recon,(Second 703 1.5.Buaheat and Prefessinu Code:Any city or county
$ which require a Permit to construct.our.impmva,dcm"1'uh.or.,it any$.to.
_Zy prior b its issuance,abo mquirm the applicant forsuch Permit in rile a signed surmount,
< wlbeislicamediP. ,atlttothepdaismvnrweContractor•.UOc.Law(Chaptna9 Sq.Ft. Floor Area Valuation
y�g (commencing with Section 7")of Division 3 of the BuslnusaM Profeessiou Code)or $10000
that he is exuepl tkrtfmm and the buss for the alleged exemption.My violation of
Section 70513 by am applicant for a permit subjects the applicant o a civil penalty of ,�p�Number OCCU
nut roma than five hundred dollars($5=. 32648022V -11U Occupancy Type
I,uownes of tits propmty,ormy wplayms with waguutie4 mk eompewtion,
avid do fewrk.and the he Cor boots Luccaam ave d forssk(Sec.an art ammr on
aria property who
Code M ve,traamra ndwho law doe tiro apply if an awuer or _ Required Inspections
Ownem who Wii provided t ave ti¢rmn,andwho amnouch work Mroff arthrough hk
awneer.me buidorthatinchimprovammtsam not intendedOBamA formic.f.
milder ,Ne building m den of pmml b halo within ane yen of completion.provfar
au ownu-
builder will haw the Omden o!proving that K did tet build or improv for purger of
sok.}
❑1,n.of the property...aaclusivelY conusting with liemn. caffinenrs Of
couwct the project(Sec.70sa,Buinrs add Profession Cade:)The Conuamoh U.
cave law does not apply in an owner of property who Indian or improves themon,and,
who contacts fm such projects with a conhacnr(s)Iimnaed p rcu ant to the Conurxtofs
License Law.
❑Iameaemplundor See .BAPCfarthisaanon
Date—
Oner
WORKER'S COMPENSATION DECLARATION
I hereby aRrm under penally of perjury one of the following declmodou:
ZI haw and will mainta(n s Cerofiau of conxnl n elf-h aura lorworkefs Comper-
on,n provided fm by Seeded 37M of the,labor Code.la the performance of the
wort for which this permit is issmd.
❑I have and will maintain Workafn Compensation Iuwanm,u required by Section
3700of the later Code.for the performance of the wort for which this Permit.issued. '
My worker's Compensation humane,main,aM Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Mss scctim need mtleccomple.d if the Permit In far ane hunatrd dollarn(SIM)
or leu)
1 certify that in the put...of the work for which this permit b Issued.l ilial ria
cmployanyWrmninany maoacrmu in bacomesubjmt in wo
Laws of Califomia.Dau
Applicant
NOTICE TO APPLICANT:es aft caking Nu Certificatesof Exemption,you u a m
.J Obecome d comp y the Wdrh Pot Compcwhis provision of the labor Coda,you must
foMwith comply with such p,ari4ou or Nb pCvnit shall he ammcd rtvakca.
'Z'-' CONSrRUCnON LENDING AGENCY
.�. I thereby sf iron that then is a coruuucunn lending
I" Y E agency for the performance:of
> de wort fur which Thin pertnit is blued(Sec.509',,Civ.CI .
GW Q Lender's Nene
M z Trader's Adorer
U O 1 cooly thaI I larva read this application and sum that the above information is
L, cortut I agree to empty with all city and county ondinunra and Aute laws minding in
0 Wilding construction,and hereby mthorim.presenatives ufthis city to enter upon the
G above-mendoned property for impaction purport
(Wal)agree to raw,indemnify cad keep he,mlem the City of Cuperum agaiut
.Frei h liabilitie,judgmcnts,coma and expeuu which may in any way amore agaiutnid City
U vZ in earned.Or the granting Of thb N.iL
APPLICANT UN
MAMO TANDs AND wCD�ALL NOf Potlrr Issued by: Date r� �-
SOURCE RR TIONS NDS AN /
i D o8 Re-roofs
Signeu.of Appli txdor ate
DOUS MAIERIAISDISCLOSUIM Type of Roof
Will the applicant or future building Omvpant nom or handle bauNou material
fined by the Cupertino Mudd mal Code.Chapter 9.11.anal the Health and Safety
Scene.155324)+ All roofs shall be inspected prior to any roofing material being installed.
de
❑Yee o
Will the applicant or future building amupanl tea cgaipment Of dmias which If a roof is installed without first obtaining an inspection,I agree to remove
omit hararan"s air contaminants as der, by the Bay Area All Quality Management all new materials for inspection.
D ri is
QYea o
I have mad the hvarWruamataMab.qui.mmu under Chamc,6.95Of the Califor-
nia Health @ SafciyCode,Seetlau 25505,25533 and25534.I undersand diuif les building
doss ml currently h .tanana Net II k y res il' cry nice Occupant or the
oup,oranes w' must bc�lpim` \ a"id"es :p7 Signature of Applicant Date
L�j All roof coverings to be Class'W'or better
Owner or mthodmd a t .
--- y r