09110153 REV1 CITY OF CUPERTIN O BUILDING PERMIT AEVISION '
BUILDING ADDRESS: 21387 KRZICH PL CONTRACTOR:ADAMS BROTH
CONSTRUCTION
.PER'S NAME: RAM&MATANGI RAJAMANI 10100 TORRE AVE DATE ISSUED:04/21/2010
OWNER'S PHONE: 4089962212
CUPERTINO,CA 95014 PHONE NO:(408)564-5207
❑ LICENSED CONTRACTOR'S DECLARtATION BUILDING PERMIT INFO: BLDG[_ ELECT f— PLUMB r
License Class Lic.# Co�� w LtLI MECH r- RESIDENTIAL� COMMERCIAL
Contractor� 5 _ Date JOB DESCRIPTION:
I hereby affirm that I am licensed under the provisions of Chapter 9 7/2/10-REVISION#1 REDUCE SQFT,REDESIGN ROOF@CEILING,NEW
(commencing with Section 7000)of Division 3 of the Business&Professions INTERIOR OPENINGS @ ADDITION OF RECESSED LIGHTING-ISSUED
Code and that my license is in full force and effect. 7/14/2010
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the Valuation:$150000
performance of the work for which this permit is issued. Sq.Ft Floor Area:
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for�1_1
APN Number:36205036.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Issued by: Date:
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source egulations per the Cupertino Municipal Code,Section
RE-ROOFS:
�.�ature__ Date—! 1 ! All roofs shall be inspected prior to any roofing material being installed.If a roof is
_ installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one or ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensatio►.,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) HAZARDOUS MATERIALS DISCLOSURE
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cu ertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by
the Health&Safety Code,Se 5,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I mi st I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued(Sec.3097,Civ C.)
forthwith comply with such provisions or this permit shall be deemed revoked. Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
-ect.I agree to comply with all city and county ordinances and state laws relating
uilding construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date