04090281 CITY OF CUPERTINO +" . .. 3(y'I �*+ , +S? �ft�" '; •rye -
BUILDINGDIVISION�m PERMIT ✓'7.A+OL\,�CTOR 4NIF.0 MA SO 9�
i"
BSUILDING ADDRESS: PERm"N�4 0 9 0 2 81
21876 W
OWNER'S NAME: PERMIT ISSUE DATE
SR & USHA VENKATRAMANAM 4
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
- BLDG ELECT PLUMB MECH -
+100 LICENSED CONTRACTOR'S DEC RATION IOb DeSCrI IIOn
Ou - 1 hereby affirm that 1 am llmneM under pro __.r
of Chaplet 9(commencing. P
with Icon ")af Dlvisio3oflo Bmedmss cW=Co ,sndmylicemis
'Imm�ra p�ndercec� ADD 343 SQ. FT. MS BEDRM/BATH
1V'�ARCHITECTS DEcu ' CONTRACTOR: REBOZZI CONSTRUCTION
I understand my ph.sled!he used As puN reed -
�rr
3 W Licensed Professional /f+ /1 n
y OWNER-BUILDER DECLARATION
i F 1 hereby alfbm that I me UMPI from the Conlranor'a Utm ae Law for the
D o fallowing rtooa.(Sudan 7031.5,Business and Profession Code:Any city or county
- $ which m ubea a Permit an eomuct,When.Improve.demolish.Or repair any atractura -
.b,i'y' prior its issuance.also requires Ile applicant fmsoch permit to file a signed Amman(cm _ _
quit hofs licensed p.m.,r the provision of de Cmaracmra Uceme Law(Ch.pmr9. Sq..Ft.Floor Area /V�Jn - U�Valt lO O;O
$ that he ncxempt hcmfmm and ax bshion]di theeged eumd on.Any
vi `/15�F��(,f� -' •ryhs�� _ - -
.� .. Nn he h exempt Ihemfrom and die buil for the the{W exemption.Any violation of Y!fff Il"
Sectio 7031.5 by any applicant for a permit subjects the applicant to a civil penally of _. a1,.... -,-
not..than It.hundred dollus(5500).' - -- AFN'NUmbeT `q �'{/// ry L]CCUpanCy I�'pe - - -
❑1,sa ownerof the property,or my employees with wages sa their sole compensation, l 32649020 . 00
� C,1.,/ �J�I
wed do thework.and lheallucture isnotintendedoroneal I...k(Sec.7044,Busimn
and Profession Cade:The Cantrat.7trfa U.Law don not apply to an owner of " . Required Inspections
propertywha Wilda orlmprowthereon,andwhodmsuch work himselforthru{h his
awnemploye .psovidedtho.himpze.mantaarenotin¢ndedoro(rcmdrns.k.if. - - - - -
however,the building aro Improvement Is mid within am year of compledda the ewer- _
builder will have use burden of proving Wt he did not build ar Improve for purpose of
' saled. .-
❑1.as owner of the property,atn esclummi conuwAn,with limned conuacmis to
cortrunl the project(Sec.7014,Business add Profession Cade!)The Cmtrmbfs U. ,.
certse Law does not apply a an owner of property who W lift or improve thereon.and. . .. .-- .
who contracts for such projects with a mnlrlerof(s)licensed pmnnnt an the CotranoYa
Licerue law. - '.- .
❑Ism exempt under Sec. .B&PCfnthismmn
Owner Data ..
WORKER'S COMPENSATION DECLARATION;;
1 hereby aElrm under penalty of perjury one of Ila following declaration:
IA..and will maintain a CeNncae of Cancer in stif.l.u.fn Worker',Campan-t' :,,;. -.
Sado.,As provided for by Scedon 3700 of the labor Code,for the Performance of Io
work for which this permit is imed.
❑I have and will maintain Wmkefs Compensation Insurance,As tequlmd by Section -
3700ofthe LAbac Code.forthe perfameancc ofthe work for which this permit is issued.
My We
eCC((iS7pernmem.1 me carrier and Policy number are: -
G .Jri'y f-C '1 c�,n /f Icy No. 2 002, C
CERTIFICATE OFEXEMPTI MWORKERS /�b
COMPENSATION INSURANCE
(ITh amo ma
dd not hecomphtad if tit permit Is fmonehundre ldoBea(S100
carless)
1 certify that in the performance of to work fm which this permit Is imed,I Nall not ..
employ any person in any manner an As in become abject to the Wmknn'Compensation- ' -
Law.of California.Data
Applicant
NOTICE TO APPLICANT.If,attar making this Ccrifinta of Exemption,you should
became subject In the Workers Compcnatlan provision of the Labor Cade,you must
rJO forthwith comply with such provision or this Permit shall he deemed rooked.
Z► CONSBUCDONLENDING AGENCY
'e~•, (hereby affirm that there h•construction lend!.,agency far the performance of
Ni? the workfor which this permit h issued(Sec.J ,Cl,C.)
Q Lendcfs Name
z lantlefs Address
V Q 1 certl(y that I have read Wer application aal sum that the also.in(omeadan la -
L,, carrem I agree to comply with all city and county oMnYwee and sub(awl relating in
0 SV' boHding construction.and hereby authorize rtprmenmlves of this city to enter upon the
move-mentioned property(m inspection parposess.
(We).,rte a W.indemnify and keep homeless the City of Cupertino agalnt
rA liabilities,Judgments,cross mns said City
rIn consequence of the granting of this permit.
APPLICANT UNDERSTANDS ANDYIV COMPLY WITH ALL NON-POINT Issued by: Date
t E C WTI S.
Signature of Applic onmotor Data Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tho applicant m future building occupant stare orhandlc haosmous material
u dented by the Cupenlno Municipal Code,Chapter 9.12,and the Health and Safety -
Code,Section 7553$a)7 All roofs shall be inspected prior to any roofing material being installed.[Dyes 64.
Will the applicant or future building oceup.nl use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
haoud.us air canominnu As dcftgcd by be Bay Area An Quality Management all new materials for Inspection.
let?
❑Yrs 790
Lha.mad thehvaNmws
materialsre ensu under Chapter 695 of
93of the
Gliory
d . d .cy mM5,25533m1 d building
d. dy tens .man ochiliytomaydaoccuPantofthe
rtyuirem emPmry.
S—ign tore of Applicant
ow r.amarivea a Ani Dam All roof coverings to be Class"B"or better L