05090189 CITY OF CUPERTINO ern , u, ; s �.:ti,r .° �" •" "" ^�,
BUILDING DIVISION PERMIT .+�-'Oi`iTRACTQI{IN.�t}RMr�TIU "
BUILDING ADDRESS: PERMIT NO.05090189 5090189
.WS NAME: PERMTI ISSUE DATE
VIVEK & JY
PHONE: SANITARY NO. CONTROL NO.
ARCHI7EC ISNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
iOp LICENSEDCONRACIOWS DECLARATION
,8�� 1 ter I em Ileeesed ns of 9(commencing Job Descriptionnon
sells Section 70M ofDivitlon)ofdie ButimamandProleaiansCoda.aed
mylicensees
Ninfull force and effam. ADD 1570 ' (2 BEDRM/RECR. /BAR/DECK,
Sig License Clue Lk.d
1
Dow—Contractor—ARCHITECTS DECLARATION
ENRY PORCH) , RELOCATE KITCHEN
I 1 undersand my Plana shall be used An public records
YU
a Aid� Licensed Prof..I ..I
OWNER-BUILDER DECLARATION
Conn It7N
<9 1 row oRm that 11. exempt from tic Canom,Co Llecnse Law for LOU
00 fallowing Musa.(Saito 7U3L5,construct,aness and Rofeotuns Code:My em m county
9 fi which its Wo a pemil se UiMw sever.hnpmsu h Farah t m repair any muerum
_iun pdarmla bmams.ala.requires the applicant for such permilw file asigrodsawmenl
< IlwheialkcucdpumnnlmlheprovisionsOftheConuactmllicenseLow(chapar9 Sq.Ft. Floor Area Val 1010000
$ (commencing with Schon 7000)of Division 3 of the Budoea and em
Preons Code)of
that he b axempt dwm0om ams the bub for the alleged exemption.Any violation of
Sadon 7031.5 by my applicant res a permit sebjaa the applicant to a civil penally of APN Number Occupancy Type
sen come than Bw hundred dolbrs(SSW). 34245010 . 00
0 I'm ownerof dim property,m my employees with wages u theksele compcwuon,
aid dothawmk,and dm he Contesrors Lrwedmaw doe
fs rule(Sec.In As,Buttwa Required Inspections
prepend arty m be Code The Conmnma License lave utas rot apply if rt owner of q P
man enywk bWpro i fmprovntheimmn,tedwk masaeachwort hMalfedthrough hes
man employees.building
pro ehimprovemmainnot intaMedmortems futile.U, '
however,the kilning or impm pro ines eat s did aro Team mmpletlfor the man".
Wilda M0 bow the burden a(proving tial k did set build w Mprow for purytse of
ea e.)/
Q u owrcr M the Property,.euluuvcly cmuuling wille licensed mntaclms N
construct the project(Sea 70/0.Business;and ProreWma Code:)non Committees U-
come Law does ore"p y w an uwnm of propmy'wim builds or improves thmem.ad,
who conmces for each projects with a comrxta!(s)Ik'anad pursuant w the Commutes
License law.
❑1 em exemPL qdp B dt P C for Wb tmeoa
v V Dae I t ZA tis
CERB COMPENSATION DECLARATION
1 hereby air=miler penalty of perjury Use:of the fmwwing dalan0anx
❑I haw and will maintain a Cer6Bm n of Conten in self-edam for Workm'aCanpen-
Aides.As provided res by Section 37M of de Labor Cads.far the perfamtance of the
work for which Nb permit is Wood.
0 1 have and will maintain Worker's Compensation Innuuue,as acquired by Secure
)700 of ace labor Code,res the performance of the work for which dee permit is leased.
My Work es Compensation huseranm carrier and Policy number am:
Carrier. Palley No.:
CERTIFICATE OF BXEMFnOH FROM WORKERS'
COMPENSATION INSURANCE
CrasseNon need not necomplemd Hthe permit b Terme hundreddo0an($101131
or lea.)
I certify that in the performance of to wart for which Nie permit is issued,I Loll our
employ any perean in any manncrm p a became adbject in tho Warken'Compensation
laws tf Cmifamii.l
NOTICE
u V
NOTICE bj APPUe Work If.afterCom conking this Canons of oft amus Cod you ehoetu
Doane subject y the Worker's Compensation or this provisions of the labor Code you muR
.J O forthwith comply with each provisions or Nb permit shall he tamed revoked.
z CONSTRUCTION LENDING AGENCY
Fw I hamhy alfirre the dem laaeonsuact o lending agency far the performance.(
C> the work for which win
permit es asued(Sac.3097.Civ.C.)
W ,soden Name
z Lenders Add.
U O I certify that I haw mad this application and saw taw the above information is
ly F carted.i agree to comply with all city and county ordlesnces ted taw laws Milan{in
O U kilCing eonswnion.and hereby amhadre Mprerenadwa ofthis city to enwrupon the
w show-menuancd pmpenY
for weimc ion pucposea
(We)agora to an,indemnify and keep hannlea Ile City of Cupertino egaiut
(AA Iiabilitu,judgmena,eosa and expemu which may in my icy seen{mink Md City
U z in eeseegmnco of the licensing of dies permit /—�7 •Z^D dC
., APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date f G
SOURCE MONS.
1112-510-5 Re-roofs �S
Sngnuure uandCa Dew 2v
HAZARDOUS
S Wilding
MATERIALS DISCLOSURE Type of Roof
Will dwapplicant or forum kalCo e.Chaptpmemand was
heealth a maarim
u dcUad by the Cupertino Municipal Cade.Chapter 9.12,and to Health and Safety
Series 25532(4)7 All roofs shall be inspected prior to any roofing material being installed.
0Yes TNa
Will we spplicant or future building Occupant use equipment err devise which If a roof is installed without first obtaining an inspection,I agree to remove
emit hanrdnw air contaminants As dclined by the Bay AMA Air Quality Management all new materials for inspection.
District?
0Yes N.
1 haw mad dine hazsAwsmaaresesmquimmena underoaper6.95 ofdoe Carter.
nix Hcolth&SafnYCmw,Semions25505,25533 wm2553d.1 umkmand daifthc building
does act currently haw a vent,that It b my responsibility to acul'y the occupant of dw
aqui nnA,gman k met prier to b®ance aft Certificate orrxcupawy Signature of Applicant Date
Gwna! E(ranaLd agCnl Dow 1 t�u) �� All roof coverings to be Class"B"or better