06100074 CITY OF CUPERTINO
BUILDING DIVISION PERMITT .
PERMIT NO.
BUILDkff f�SSdOLLYMAN LN-LOT 2 TBD TO BE DETERMINED 06100074
L U y PERMIT ISSUE DATE
� ";R'S NAME:
DIPESH GUPTA 05/02/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p 0O LICENSED CONTRACTOR'S DECLARATION Job Description
%uI hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code.and my license is 2 STORM : 2882 ' GARAGE 441 ' BALCONY• UNC OVERD 60 '
t a a- in full force and effect.
; z License Class Lies PORCH: UNCOVERED- 280 ' COVERED- 120 ' ADDRESS
�w Datecontractor
CLARATION CHANGER FROM 10752 S STELLING RD.
a< I understand my plans shall be used as public records
)aU
U.y Licensed Professional
H
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
po following reason.(Section 7031.5,Business and Professions Code:Any city or county
<
Q. which requires a permit to construct,alter,improve,demolish,or repair any structure
Zy prior to its issuance,also requires the applicant for such permit to file a signed statement
=c that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 sq.Ft. Floor Area Valuation
t—$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $6.58305
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 to a civil penalty of 3 5 9 2 2 0 E 1 A��Number Occupancy Type
not more than five hundred dollars($500).
❑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 (1 p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements arc not intended or offered for sak.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.).
®1,as 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 contractor(s)licensed pursuant to the Contractor's
License Law.
❑lam
exemp du Sec �.B&P C f this rcawn
-r G'DWz C ��
WORM'S COMPJaIf DECLARATION
I hereby affirm under pe of perjury one of the following declarations:
❑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.
❑I have and will maintain Worker's Compensation Insurance,as icquired by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation htsuntace 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(S 100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any perso in any manner so as to becomes jest to the Wo rs'Co pcnsation
Laws of Californiaa
Applicant
NOTICE TO APPOCA :If,afacr makisate of Exemption,you should
become subject to the Wo is Co n rasions of the Labor Code you must
Oforthwith comply with such p ons or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
F~—t►�-. I hereby affirm that there is a construction lending agency for the performance of
�Y �✓ the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
z Lenders Address
U 0 1 certify that 1 have read this application and state that the above information is
w► correct.I agree to comply with all city and county ordinances,and state laws relating to
0V 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
Hliabilities,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 UNDE[,&TANDS AND WILL C MPLY WITH ALL NON-POINT Issued by
SOURCE R TIONS.
0rfo lz ' to-roofs
Signaturcof Applican ontractor Date
Type Of R oof
HAZARDO 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
•le,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
C]Yes futDNo
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emh hazardous air contaminants as defined by the Bay Arca Air Quality Management all new rr aterials for inspection.
District?
❑Yes ONo
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 c oily havra tenant,that i is my responsibility to notify the occupant of the
mquircmcn hmustbe pri issuancco rtcatcur 0 gnatureofApplicant Date
All roof coverings to be Class"B"or better
Owner or authorized a crit Datc