07090033 CITY OF CUPERTINO ' � � T, �
;
BUILDING DIVISION PERMIT ��������A� y�`'�'
;: . . ,;.: . _ ::: , ,:.:. :::
BUILD N DDRESS: PERM►TNO.
���9 DERBYSHIRE DR OMEGA C�NSTRUCTION 07090033 •
OW NER'S NAME: PERhtIT LSSUE DATE
� KHILNANI R.ATNA & SARAT 451 FEN�EY AVE 10 7
�g; SANiTARY NO. CONTROL NO.
(408)243-0404
ARCHiTECT/ENGINEER: BUILD[NG PERMITINFO
BLDG ELECT PLUMH MECH
a o 0 0
i o p LICENSED CONTRACTOR'S DECLP.RATION
; v� 1 hcrcby afficm that I am liccnscd undcr provisioas oC Chaptcr 9(commcncing Job Description
; z W with Sccuon 700U) of Divisian 3 of ihc Busincss and Prokssiuns Code and my liccnsc is REV I s I �J J — R P S TI� S TRUC L PO S T I N FM RM & ( � R I(s
?� y in full Corce and cfCect
��? LicenscClass �ic.x #070401 �7 ) REPSTN FIREPLC � REPSTN STRUCT PST IN
��"� � pRCHITELTSDEC BTHRM 1, RPSTN CLST IN BDRM & CRWL SPC ACCESS TO
�� U 1 undcrstand my plans shall bc uscd as puhlic records
,a
� p y Liccnsed Profcssional
� y � OWNER-BUILDER DECLARATION
�<� I hcrcby alTirm �at 1 am cxcmpt Crom thc Contractor's Liccnsc Law Car t6c
_ p O following rcason. (Scctian 7031.5, Busincss and Profcssions Calc: Any city or coun�y
e°„ �i which requires a permit to conswc4 altcr, improve, dcmolish, or repair any stn�cwre
° Z} prior w i�s issuancc. alw rcquires ihc applicant [or such pertnit w filc a signccl statemcnt ��, Ft. Floor Area Valuation
�_< tha� he is liccnscd pursuant to thc provisions of U�c Comractur's Liccnsc Law (Chaptcr 9 .�Cl
y F- $(commcncing with Sccdon 70W) of Division 3 oC ihc Busincss and Profcssions Codc) or $ Q
y �... that he is exempt thcrefrom and the basis Cor t6e allcgcd exempdon. Any violation a[
Section 7031.5 by airy applicant for a pertnit subjects the applicant to a civil penalty of � Number Oceupancy Type
not more �han fivc hundred dollars (SS00). 3 6 2 1 9 O 2., ��
❑ I, as owner of ttie propeny, or my emplayces with wages u the'v solc compensation,
will do the work, and �he structum is not intended or aftered tor salc (Sec. �044, Buan�ta Re u ired Ins ections
and Professions Code: Tlu Conuactor's License Law does �rot apply w an owner of 9 P
propeny who builds or improves thercon, and who does such work himself or tluoagh 6is
own emplayccs, provided that such improvemen�t are not in�ended or otfered Cor sale If,
howevcr, the building or improvement is sold within one year oC complcdon, the owrcr-
builder will have the burden o[ proving Wat he did not build or improvc for purpose of
sak.).
, as awner of the property, am exclusively conlraaing wi�h licensed conuxyns lo
construct the pmjett (Sec. 7044. Businus and ProCcssions Code:) The Contrxtors Li-
ccnse Law does not apply io an ownu of property who huitds or improves Ideeeon, and .
who conuac�s Cor such projects with a contractor(s) licensed pursuant to �he Cantnetofs
License Law.
❑[ am aempt undu . B dc P C f t6is
3
ow� oa� � �
WORKERS CdMPENSATION DECLARATION �' ' " -
I heccby �rm under pcnalty ot pery'ury one of U�e fallowing declaratiunx
�] I hsve and wi11 maintain a Certifip�e of Consent to ulf-inswe for Workcr's Campen-
sation, as provided far by Section 3700 af the I.abor Code, for the performaixc of ihe
work for which Ihis permit is issued.
❑ I have and will maintain Workcfs Compensadan Insunnce, at reyuired hy Sectian
3700 of thc Labor Cadc, for thc performancc of the work fa which �his permit is issued '
My Workers CompensaGan Insurancc cartier and Poliry number are:
Carrier. Policy No.:
CERTIFlCATE OF EXEMPI70N FROM WORKERS'
COMPENSAT[ONINSURANCE •
(Ch�s section necd not bc completcd i( the permit is for onc hundred dollars (SI00)
or Icss.) .
i cenify il�at in thc per(ormancc of thc w rk (or ' �his pertnit is issucd, t stwll not
e�ploy any person in any manncr w as � subjcct to the Workcrs' Compensation
Laws of Califomia. Datc J
Applicant
NOTICE'f0 APPUCAM: If, aftcr making �his Ccrtitica�c of Faccmption, you should
bccome subjcct to �he Workcr's Compensation provisions of �hc Labor Codc, you must
. O foMwith comply with sueh provisions or this pecmi� shall be decmed revoked.
� °"" CONSTRUCTION LENDING ACENCY
.-�
(-r � I hcrcby aRirm Wat thcre is a conswction knding agcncy for thc performancc af
Ri � ihc work fur which this permi� is issucd (Scc. 3097, Civ. CJ
W� Q L,endcr's Namc ,
� � l.cnder's Address
V Q 1 cenify U�at I havc read this application and suie �hu the a6ove informaGun is
w� correc�. 1 agree ta comply wi�h all ci�y and county onfinances and sute laws relaung to
� U building conswction. and hcrcby authome reprcscntativcs of this ci�y to cntcr upnn �Ac
� W ahove-mcntioncd property for inspcction purposes. (
a (Wc) agree to save, indcm�i(y and kecp harmless lhc City o( Cupcnino againtt � �
�� liabilities, judgmcn�s, costt and expcnscs which may in any way accrue against said City
(} ,'� in conuquencc oC thc granting of ihis permiG �f �
►'i APPLICANT UNDERSTAND ND W1LL COMPLY W A�LL NON-POINT Issued by: Date - G.� "��
SOURCE REGULP�'ION '/ y 1/ V_ (� � O� Re-roofs �z
� � G"[.�►� �
Signaturc of Applicant/Conuactor Date
HAZARDOUS MATERIALS DlSCLOSURE Type of Ro �f
Will �hc applieant or futurc building oeeupant storc or handlc harardous maoerial
az dc6ncd by 1hc Cupenino Municipal Codc. Chaptcr 9.12, and �hc HcaIW and SaCety
c��, s��uo� zss3zca>� All roofs stiall be inspected prior to any roofing material being installed.
❑ Ycs o
Will �hc applicant or futurc building occupant usc cyuipmcnt or dcrices which If a roof is installed without first obtaining an inspection, I agree to remove •
cmit harardous air conuminan�s az dcfincd by ehe Hay Acea Air Quatiry Managcmcnt all new ma :erials for inspeckion. �
0�5«���� ,
❑Ycs �.�vu
V
( havc read ihe ha�ardcws matcrials rcquircmen�t undcrChaptcr6.95 of �hc Cali(or-
nia Hcalih & Safcty Codc, Secuons 25505. 25533 and 25534.1 undcrstand �hu if Uic Miilding
docs not curtcntty ha a �cnan4 �at 't is my responsibility to noril'y Uic occupant nf ihe
rcyuircmcn�swhich i �p�rtoissuancco[a�fOr�upaqqy.�� SignatureofApplicant Date
'� l�fJ
Owncrocau�horizcdagcnt p„� � . All roof coverings to be Class "B" or better