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CITY OF CUPERTINO
ON PERMIT
C�It�iCTCf I1rI�*
BUILDING DIVISION
BUIL gfV DRESS:
1U��1 NORTHOAK SQ
TBD — 70 BE DETERMINED
PERMIT NO.
07060017
OWNER'S NAME:
PERMITISSUE DATE
MURUGAN, RAJMOHAN
06/22/2007
NE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
� 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
REMODEL BATHROOM AND HALF BATH
in full force and effect.
License Class Lic.ff
MINOR STRUCTUAL, INCLUDES LIGHTING
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
3 Business Professions Code)
$9000
(commencing with Section 70)00) of Division of the and or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
31641022. Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars ($500).
0 1, as owner of the property, or my employees with wages as their sole compensation,
ns Required Inspections
�l p
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
las owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a conuactor(s) licensed pursuant to the Contractor's
License Law.
0 I am ex t under B& P C for this reason
_Sec'`�/w�
Owner JY�— �"C \ Date
ORKER'S COMPFNSA71ON DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code. for the performance of the
work for which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($I00)
or less.)
I certify that in the performance of the work for which this permit is issued. 1 shall not
employ any person in any manner as to,. come subje to rkers' Compensation
Laws of Cal' ia. Bate —
Applicant �n•�
N6110E LI NT: If, after a 'ng this Certificate of Exemption, you should
become subject to the Worker's Com nation provisions of the Labor Code, you must
forthwith comply with such provision or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (See. 3097, Civ. C.)
Lender's Name
Lender's Address
I 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
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way accrue against said City
A�l
in consequence of the granting of this permit.
j AP ICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by Date
S CE REG ATIONS.
2'9
Re -roofs
Type of R oof
Signature oNApplicanttCoWactor Dale
HAZARDOUS MATERIALS DISCLOSURE
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
Code, Section 25532(a)?All
roofs shall be inspected prior to any roofing material being installed.
❑Yes &r6/.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or de�ic� which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new rr aterials for inspection.
District?
0 Yes ❑1Vo
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not ntly have a tenant, that it is my responsibility to notify the occupant of the
require s w ch must be met prior to issuance of a Certificate of occupancy.
Signature of Applicant Date
2 L tnN'`)Qt
All roof coverings to be Class "B" or better
Ownero author ed agent Date