07020049 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C�1NR19�GT+OR Ik`�RM' TIE�I�i
PERMIT NO.
BUILDING ADDRESS:
10640 JOHANSEN DR TARA HOKES 07020049
PERMIT ISSUE DATE
OVINER'S NAME:
SUBRO KOLLAR 20200 LJCILLE AVE APT 41 03/14/2007
SANITARY NO. CONTROL NO.
SNE:
(408) 253-7828
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
i j p LICENSED CONTRACTOR'S DECLARATION Job Description
%m I hereby affirm that I am licensed under provisions or Chapter 9(commencing
Zwith Section 7000)of Division 3 of the Business and Professions Code,and my license is REV I S I O N• STRUCTURAL & ELECTRICAL & PLUMBING IN
?=y in full force and effect. GARAGE
? License Class Lic.#
p Date ARCHITECTStractor DECLARATION ORIGINAL PERMIT: 06100001
7 z< 1 understand my plans shall be used as public records
)0.V
a y Licensed Professional
a a OWNER-BUILDER DECLARATION
a_j I hereby affirm that I am exempt from the Contractor's License Law for the
p C following reason.(Section 7031.5,Business and Professions Calc:Any city or county
< which requires a permit to construct,alter,improve,demolish,or repair any structure
y prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
z, p Ft.Floor Area
S that he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9 Sq $5000
r L- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
3 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Number Occupancy Type
not more than five hundred dollars(3500). 3 7 5 3 6 0 C
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
C3 L as owner of the property.am exclusively contracting with licensed contractors to
construct the pmject(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
0 1 am exempt un r Sea B&P C for this reason
Owner Date
WORKER'S mmPENRHON CLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workces Compen.
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(-this section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any mann as to become subje t to t c Workers'Compensation
Laws of California.Date -
Applicant --Te
NOTICE TO APPLICANT:If,after making this Ccmficatc of Exemption,you shoul
become subject to the Worker's Compensation provisions of the Labor Code,you m
.�• Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
W A
Lender's Name
Lenders Address
U C) I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to
J J building conswction,and hereby authorise representatives of this city to enter upon the
W about-mentioned property for inspection purposes.
0. (We)agree to save,indemnify and keep harmless the City of Cupertino against
rF-a liabilities,judgments,costs and expenses which may in any way accrue against said City
U z in consequence of the granting of this permit Date
�+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b>-:
SOURCE REGULATIONS.
e L9 /�� -tt. 'Re-roof: �1
Signature of Applicant/Contractor Dare Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.ghaptcr 9.12,and the Health and Safety
Code,Section 25532(a)? /�
lAll roof;shall be inspected prior to any roofing material being installed.
[3 Yes Yes N
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, agree to remove
emit hazardous air contaminants as dcrrned by the Bay Area Air Qu fly Management all new materials for inspection.
District?❑Yes u
I have read the hazardous materials re uirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant that it is my responsibility to notify the occupant of the
requirements which must be et prior to issuance 4f Ot Ce ficatc of Occ�PT,4 igna tut e of Applicant Date
1 y All roof coverings to be Class"B"or better
Owner or authorized ag n
Date