05040112 CITY OFCUPERTINO
Q'• m� '-
BUILDING DIVISION PERMIT CONTRACTORjNFORMATIQN a
BUILDING ADDRESS: NATIONAL ROOTER PERMIT Ncb 5040112
22466 LINDA ANN rT
OWNER'S NAME: PERMITLSUE DATE
Ail JAWAHAR MALHOTRA 2911 MONR
10 ONE: SANITARY N0, CONTROL NO.
(408) 241-0887
ARCHITECrfENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Lop
LICENSED CONTRACTORS DECLARATION JobDescri tion
to F❑ I hereby affirm that 1 am Emosed under provisions of Chapter 9(commencing P
IW with Saction701kq of Division of Or Business and Professions Code.and my license is
^`may in full fame and effect. y aJ REPIPE (FROM MAINO TOPFIXTURES)
jgf? Licenmaxis Lla.0 _
F
A CHITECrS DECLARATION L '• s. ,f_u _l
U1 understand my plans shall W used as public records
u.tLicensed Pntfcssional
O OWNER-BUILDER DECLARATION L sJ
i y 1 W reby affirm Nat I am exempt from One Conuacmr's License Law for the
00 following mason.(section 713 L5.Business and Prores Tom Code:Any city ar county
%m which requires a permit to cunslmel,alter.improve.demolish,or repair any stmeturc
Fey prior In its issuance,also sequins the applicant for such permit to rile a signed statement - -
ISo dtatheislicawdpunuantmlhepmvisiomofthcCon=tor'sUa claw(Chapter9 Sq. Ft. Floor-Area '� �� Valuation
WI-0 (commencing with Section 70110)of Division 3 of the Business and Proressiom Code)or 4 8 a Q
y that K u exempt tharfrom and do thou for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant 10 a civil penalty of APN Number Occupancy
not more Nan Gw handled dollars(53001. P Y Type
❑I,as owmr of die propmty,or my employcu with wegu a the'v sole wmpenati0n,
will the On work.md Nextmemrt is not intended or offered mrxale(Sa.7044.Bud. 022613071 . 00 Required Inspections
and Profession Code:The Conoacmrs License law does not apply m an owner of - q p
property who Wildsm improves Norton,and who dwssuch work himselforthrough his
own employees,provided that such improvements ase not intended oroBered for We.If,
however,Nc Wilding or improvement is said within one year of completion.On owner.
builder will have the burden of proving that W did not build or improve for purpose of
ate.).
❑1,as Owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7014.Business and Professions Code:)The Conmcwrs Li.
am Law docs not apply to an owner of progeny who Wilds or improves demon,and
who contracts for such projects with a commucmr(s)hearted pursuant to d¢Contractors
License Law.
❑I am exempt under Sao ,B k P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury tam of the fallowing declarations:
1 ham and will maintain a Certificate of Consent to self-insure for Workers Compery
sation,u provided far by Section 3700 of Or IaWr Code,(or On performance of the
work far which Of,permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labw Code,far Ne Performance of the work fru which his permit is issued,
My Workers Co1mp-ens/at�ion Insunna��/o1rricr and Policy number au:
Cartier: S�u•I-e_fiI/V•C� POIIcy No.: - y
CERTIFICATE OF EM MON MOM WORKERS'
COMPENSATION INSURANCE
(Thu section mail not be completed if the Permit is far one hundred dollars(SIM)
or it..)
I mrtifv that in the performance of the wart for which this permit is issued,l shall not
employ any person in any manncrsn as,to became subject a the Workers Compensation
Laws or California.Dau
Applicant
NOTICE TO APPLICANT:IL after making Nis Conifcau of Exemption,you shouW
We me subject to the Workers Compcnation previsions of Ne labor Code,you mum
.Jz rorOwith comply with wen provisions or this permitmWII W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[-r I hereby affirm that there is a construction lending agency for the Nrfurmanm of
FC
the work for which this pcmot is issued(Sec.3397,Civ C.)
i[1 Lender's Name
a Uhders Address
az
U 0 1 certify that 1 have read this application and sou that the Orin information is
" P C09CCL I agree to comply with all city and county ordinances and some laws relating to
0 U building Construction.and hereby amhorim momere utives of this city to tour upon Ne
C aWvomentioned property for inspection pupmes.
(Wo)agree to ave,indemnify and keep harmless the City of Cupertino against
F' y lothitides.judgments.costs and expcnea which may in any way at.against said City
U in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATr�.
w
Signature of App � tractor Dau Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dx applicant or future Wilding oceupant alert or handle hvudoa matelot
ar defined by the Cupenino Municipal Calc.Chapter 9.12,and the Health and Safety
i sectioVes n 25532(x)7 �4a All roofs shall be inspected prior to any roofing material being installed.
�
LWill the applicant or rutum building Occupant use equipment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
I havzrdous air contaminants a declined by the Bay Area Air Quality Management all new materials for inspection.
Districtt
❑secs ' Ra
I have mad the haardous materials mquimmcnts under Chipur6.95 of the Califon
nia Health G Safcty Codc,Sections 25515.25533 md25534.1 undcutand thxtifthe building
ones not currently haw a unapt.On it u my respr ihility to notify she occupant of the
myuimmcnka whmh mut beton pri�rmissuma or.certinea0 of occupancy. Signature of Applicant Date
G
Owner or moRLagent Dam All roof coverings to be Class "B"or better
CITY OF CUPERTINO
' REPIPE/SEWERS/MAIN SERVICE
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN #
Building Address:
-;L24164
Owner's Name: Phone#:
a
Contractor: hone: License#:
CG�79nJa/ oo�i Yob oay�-d8 7693oD
Contact: 1��-�� Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential Commercial ❑
Cost of Project:
•
Qty. if
Applicable Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING