05020168 CITY OF CUPERTINO ;w•Fw:�'>*ter s'sii. ' ' "•�
BUILDING DIVISION PEF MIT fCO1�iTRACTI IDR INFOItMA 40N: '
BUILDING ADDRESS: SEEMA MI TTAL """05020166
21949 LIMY IN T,QT I
OWNER'S NAME: PERMIT ISSUE DATE
IS SEEMA MITTAL
NE: SANITARY NO. CONTROL NO.
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
OEO PLUMB M�ECH
30p
LICENSED CONTRACTOR'S DECLARATION Job Description
1 malty&Man that i ane licensed under provisions of Chapter 9(commencing
wise Sacdan 7")ofDlvWan 3 of the Business and Professimu Code.old my license I-
n nfullin=andeffea SFDWL-2 STORY (5484 ' -LIVING)
Dau
Ueenmela Comment, GARAGE 707 'ARCHITECTS DECLARATION
all1 undersunJ my rbm shall he used as Public rmnrds
c Licensed Professional
^ OWNER.BUILDER DECLARATION
4 I hereby afnrm that I em exempt from the Camnclors Licence Law for the
m o fallowing A.(Scotian 7031.5.Business And Prefca.W.Code:My city or County
$Pi which requires a permit to conslruc4 alar,straw.dcmalim.or mpair Any Mremu e
!^ prior m its issuance.also requires the applicant Intranets permil at rile a signed su anem
< Nal he b licensed pursuant to the provisions of the Commumrs IJcease Law(Chaper9 Sq. F[.Floor Area V"IdIuo 00
9 (commencing with Seclion7000)af Divuion3ofthe Businessand Professlnn.Code)m
�l
that he k attempt Nemfrom and the bub fm Ne alleged corruption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant in A civil penalty of APN Number Occupancy Type
nm mart Nan Ow hundred dollars($5001.
❑I,ss owner of Ne pmpeny,or my employms with"Sea u tha'usek CompemOm. 35625026 . 00
will do the work.And the mocava bort rounded Crafted fomle(See.7044,Business
And Profevsiom Cade um
The Consem Liamm e law does not apply an awaer Of Required Inspections
property who builds or impaws thereon,and who doesAoch waak himsel f ar threats his
awn employees,provided that such Improvements art an,internist OroResed fessAk.If.
ha never,the Building or Improvement is mid within Can year of to mpledm,the Owner.
Wilder will haw the burden of paving Nat W did not Wild or improve for purpose of
uk).
I,As owner of Om progeny,am exclusively contracting with licensed comm.to
omtroct the Reopen(Sec.7044•Business and Proressiam Cede:)The CmUmmors Lr.
I.
Law does not Apply to an owner of properly who Wilds or improwa desmon,and
veld anuacu for such projects with a eontrseser0)licensed museum m We ConumrorA
License law.
❑Iam tieaJlRjII un ft See. B@P C far this rramA
Owner e> — /"`�`1"• —v
Data J'
WORKER'S COMPENSATION DECLARATION
1 hereby Anne under penally of perjury ane of Nc following declarations:
❑1 hew And will malnuln aCertlOUteof Coment o wlrinsum for WmkersCampen-
ution,As provided for by Section 37M of the Labor Code,foe me performance of the
work for which this permit is issued.
❑1 Mw And will maintain Workers Compeneadon lomnnm.As mquimd by Sudan
3700 order LAWr Code,for the performance of the work for which this permit is Issued.
My Worker.Compensation Insurance carrier and Policy number Me:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Mmtim need not bocompleud time Permit Mora.hundred dollars(SIM)
or leu)
1 modify that in the Performance of tits work for which thin Permit is mussed,l shall not
employ any person in Any manner m y u bCcyroSmblecllOihaWarl¢n Campenution
LAwM of Califarpi{Dau
Applicant
NOTICE TO APPLICANT.Wong If.es alum making rob Ceti ns of or Labor iOn.
.y should
bmomeecomty it Wortero Compensationprovisionsmm of the Labor Cede,youmot
O foMwrN comity with such provisions as Nis permit NAZI W d,emW n:wked.
'Z y CONSTRUCTION LENDING AGENCY
(—t I hereby affirm mat Nem Is.Consuucim.lendrngagency for Use ludormanceof
a> Ne wank fm which this peamll Is weed(Sec.3091.Civ.C.)
Alandcrs Name
.7 z Leaders Address
U0 1 certify that 1 haw mad lids Pplication and Mule that the above Informniun is
U�h comm.I agree to Comply with all city and county ordinances and sou laws-1-611110
0 Wilding comtmctiun,and hereby authodm representatives of Nis city to enter upon the
W above-mendomd Property for inspection Purposes.
(We)agree o saw,indemnify And lamp harmless the City of Cupertino Agaimt
Taq
liabilities judgments,costs and expense,which may in any way Accuse Against Aid City
rJ 7 in consequence of the gnndng of this permit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOUKpcE REGULATIONS.
-'A� kL,\O'k1 vol Re-roofs
Signature ofApplican/Canuacmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or run=building occupant Mom orhandlc harerdoos material
As denmd by if.Cupertino Municipal Cad,.Chapter 9.13.and Use Health and Safety
C7DiMrIct?
d,.SmdaO 35533(.)7 All roofs shall be inspected prior to any roofing material being installed.
El Yes �No
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
lt hannioos air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
❑Yes X.I haw test the hazardousmatealab requirements underChpur695 ofthe cane•
HUINh SsfetyCode.Scmeas 25505.25533 and 35534.1 undcrsund thadifmo Wilding
s not currently haw a uncal,mad it b my responsibility m notify Ole= pan,of the
' menu whichmuuWmlpnorm' van nccniOUmofoccupaney. Signature of Applicant Date
Owner urmlharizcde mI te All roof coverings to be Class "B" or better
G