07050123 77777777777777777'. 777777777=
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
c1 ' ' ,�T+ IYRITIf3N�
PERMIT NO.
BUILDJJN DRESS:
1��51 S DE ANZA BLVD NELSON GON21ALES 07050123
OWNER'S NAME: CUNSIENUCTIC) PERMIT ISSUE DATE
�M GOPAL 2235 STORY RD 05/15/2007
SANITARY NO. CONTROL NO.
NE:
(408) 390-5659
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
i 0 p LICENSED CONTRACTOR'S DECLARATION Job Description
V p 1 hereby affirm that I am licensed under provisions hapter 9(commencing
?ZU withScction70(l0)ofDivision3ofthcBusinessandProfe dmyicen is TEMPORARY PERMIT-30 DAYS ONLY-EXPIRES 6/15/07 .
a in full force and effect
; z License Class Lic.ri �'S 1�1 ORIG #07050065 STILL IN PLAN CK. NO FINALS ON
yLu
Date ARCHITECTS Contractor
DECLARATION THIS
1 understand my plans shall be used as public records
)WU PERMIT.
t n,ti Licensed Professional
7 a 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
which requires a permit to construct.alter,improve,demolish,or repair any structure
u—res
prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
that he is licensed pursuant to the provisions of the Contractor's Liccnsc Law(Chapter 9 Sq.F..Floor rea 0
Y t— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
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 to a civil penalty of "I Number Occupancy Type
not more than five hundred dollars($500)_ 35917001
_
❑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 offeredforsale(Sec.7044,Business Required Inspections
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 wNE"'On
dof ving that he did not build or improve for purpose of
axle.). y
15(c
❑1,asproperty.am exclusively contracting with licensed contractors to
contract 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 contractor(s)licensed pursuant to the Contractor's
LicenseLaw.
❑1 am exempt under See. B&P C forU4reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
CJI have and will maintain a Certificate of Consent to self-insure for Workers 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:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed if the permit is forone hundred dollars($100)
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 ma r )has to become sub[ct to the Workcrs'Compensation
Laws of California.Date 7
Applicant fp
NOTICE TO APPLICANT.If,after malting this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Cade,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[~i 4 1 hereby affirm that there is a construction lending agency for the performance of
Q! > the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
Z
Lender's Address
U C) I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating to
rJ U building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
G>ti (We)agree to save,indemnify and keep harmless the City of Cupertino against
fn liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
�+ APPLICANT UNDERSTAN 5)AND WILL COMPLY WITH ALL NON-POINT Issued by: Sc
SOURCE REGULATIONS ,
k�/ p Re-roofs
Signature of Applicant/Conuactor Dare Type Of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will tie applicant or future building occupant store or handle hazardous material
as defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Cod.,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
n.� �
❑Yes ❑N USN"Y f IIf a roof is ins(alled without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materi ils for inspection.
District?
❑Yes 0N (tO�— ot���15 �A
1 have read the hazardous materials requirements under Chap ter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a e that it is my responsibility to notify the occupant of the
requirements which m t nor issuance of a Certificate of Occupan f Signature of A aplieant Date
, I� d All roof coverings to be Class"B" or better
Owner or authorized agent Date