06090049 CITY OF CUPERTINO
+rw� TC?R I� RITT�N
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO. 0 6 0 9 0 0 4 9
21321 COT,UKRUS AV PERMIT ISSUE DATE
"""'ER'S NAME:
I_ NARAYANAN
PAONE: SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
0 � 0
O p LICENSED CONTRACTOR'S DECLARATION Job Description
U p I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is
;may in full force and effect. ADD 611 ' -MASTER BEDRM, BREAKFAST NOOK, UTILITY RM
? License Class Lic•8
t- Dale Contractor GARAGE 513 ' . REMODEL 345 ' ENTRY & 3 BATHRMS
„t ARCHITECTS DECLARATION
i a< I understand my plans shall be used as public records
�yU
U.y Licensed Professional
y< OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
3 p ason.(Section 7031.5,Business and Professions Code:Any city or county
% O following reit to construct,alter,improve,demolLch,or repair any structure which requires a perm
Z y 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 License Law(Chapter 9 Sq.Ft. Floor Area
t-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $194680
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 APN 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 35 LJ q U U U URequired Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q p
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.).
I,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.
❑I am exemppt� l ,B&P C for this reason
.r !!1 Date
WORM'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to selr-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 required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workees Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
1 certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to b come subject to the Workers'Compensation
Laws of California.Date
Applicant lylV�( -•
NOTICE TO APPLICA :If,Ar making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constructinn lending agency for the performance of
pC the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lendcfs Name
az Lender's Address
V Q 1 certify that 1 have read this application and state that the above information is
LL►� correct.1 agree to comply with all city and county ordinances and state laws relating to
O U building construction,and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
nWi (We)agree to save,indemnify and keep harmless the City of Cupertino against
to 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
h-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: �v
SOURCE R GULATIONS
2 (C�«I�� Re-roofs
Signature CApplical t/Contractor Da1C Type of Roof
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
dc,Section 25532(a)? � All roofs shall be inspected prior to any roofing material being installed.
C:]Yes J3"o
If a roof is installed 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 cfined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes o
1 have read the hazardous materials requirements under Chapter 6.95 of thc Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does notcurrentlyhave a tenant,that it is my responsibility to notify the occupant of the
rcqui;c which mu met prior to issuance of a Certificate of°�cupancy. Signature of Applicant Date
t, 12�bid All roof coverings to be Class"B"or better
Owner or author .cd agent T— Date