04060124 CITY OF CUPERTINO V ti p " �
BUILDING DIVISION PERMIT CONUACTORINFORMATION
BUILDING ADDRESS: AMAR GUPTA 111I1ND04060124
22975 BALB A RD
NEWS NAME: PERMff LSSUEDATE
AMAR GUPTA EL CERRITO RD LOT 11 12D.04
E: SANITARY N0. CONTROL NO.
(408) 868-1640
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u Opp LICENSED CONTRACTOR'S DECLARATION O O O O
I thereby affirm that I and licensed ander Incour ns of Chaptor 9(commencing Job Description
w'us eN
Srn 700)of Division 3 of be Business;and Professions Code.and my license is
j qmfuuforceandeffect. REVISION—RET.WALL/SLAB FOR WATER TANK
Z License Clus Lic.g
Z'o Date Contractor NO NEW PERMIT ISSUED/ ORIG. #03080119
ARCHITECTS DECLARATION
I undcrsland my plans shall used as publics recnds REVISION—#04030203
JyU
L'r:cnsed Pndcssinnal
S OWNER-BUILDER DECLARATION
commuDN
10 1 thereby arum that 11. exempt(ram the Conlns Cox License taw for IW
p o following reuon.(Seeman](131.5,Busher,and w,dcsio l Code:Any city at s county
$O which requires a permit m construct,,licca improve,demolish, file
meanie any amemnt
FZi that heor its issuance.pursuant to
lM applicant for such the Contrannitm Olead,Law(Chapter
s< (commincingxdpwith Sectiotmlhepn 70M) fDiviounfision 3 oftheBusines and Pnefeed Chap¢r9 Sq. Ft. Floor Area Valuation
al i�$ that W is exempt IMrtfrom and she hues for IW alleged exemption.Any=o! $107
Section 7031.5 by any applicant for a permit subjems the applicant In a civil Penalty of APN Number Occupancy Type
not mart than Rae hundred dollars(5300). P Y ,
0 1,as owner of the property or my employees with wages in Weir sok compensation,
will do the wart and We sweurt is net imteMW Or oRertd for We(Sec.70x4,Bush..• 00
and Profession Code:The Committees License Law does not apply to an owner of Required Inspections
Property who builds or improves thereon,and who does such work homelier uuough his
own employes,provided Wal such improvements sure not intended at oRerml for We.If,
however,We building or improvement is sold within ouc leu of completion.We owncr-
builder will have de burden of proving that W did not Wild or improve for purpose of (� -
VIe.I.
rh� d
er of ct Sm.7property,.B excessively Professions with ) no Ccanmacmrs i. `
project(Sec.7044,Business and Professions Code:)The Confeuror's sad _ w
Law ctrl such
teas with, o(property who Wildsor improves Commuc,n's V
ts for such pmXce with a conlractor(q licensed purwam a he C,ntrxmes \
. ` ^
mpl under Sce ,B b.PC for Wis rtu�anI sDate.l /I�1)L4
j 'S COMPENSATION DECLARATIONaffum under penalty of Perjury orae of the following dedanti,ns:
d will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as Provided for by Section 370 of the labor Code-6't%d perfowance of the
weak for which this permit is issued.
0 1 have and will maintain Worke's Compensation ensufuce.as required by Section
370 of he LAW,Code,for de pdrf sacrum a of die work for which this .it is LVhed.
My Werkeea Compensation Insurance carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(Thin section need not W completed If to Pewit is for one handrtddollars(SIM)
or less)
I anify that in the performance of the work for which this Permit is issued.I shall net
employ any person in any manner an as m Wcome subject to the Workers'Compensation
Laws of California.Dau:
Applicant
NOTICE TO APPLICANT:IL after making this Con10Cate of Exemption,you should
become subject m he Worker's ComPcnsedon provisions of the Laher Code,you mug
.J z foMwih comply with such provisions in this permit shall W deemed ranked.
'ZO CONSTRUCTION LENDING AGENCY
[-+ N� IWn by which
than Italia uad( ee.constructionlending agency for me performance of
fx she work fur which Nis permit is issued(Sec.3097,Civ.C.)
Qhander's Name
z 4ndees Address
U0 1 certify that 1 haw read his application and gate that the asive information is
IL E COMCL I asme m seem wish all city and county ordinaries and se laws relating to
C)SU-' Wilding construction,and hereby auhorin mprttentadws of this City 10 enter upon We
yshow-mcnudgm property for a pccWn purpowhich ms.
(Wall agree to few,indemnify and keep handless he City of Cupertino against
Z incoidesjuem of the
colastold expenses;which may in anyway azcnhe againitsaid City
U z APPLICANT
UNDERSTANDS
RSTgranAN S ANDds WILL
Issued by: 04 ate
'-" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULA S. h
Re-roofs
Signet a of Y n n or
Dam
HAZARDOUS MATERIALS DISCLO Type of Roof
applicant or future building occuoun,99&1fr handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
IDULliet'
le. 0y.25s3x(an aaa��t All roofs shall be inspected prior to an roofing material beim
Orta 1p�Ne P P Y g g installed.
Will the alaticam or future building cmuplon use,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t Wvardnus air com or imams as&fined by the Bay Area Air Quality Management all new materials for inspection.
O YesI have mad Ne hadamsma materials requirements under Chapter 6.95 of dee Califon
Health&SafetyCede,Secuon 25505,25533 and 25534.1 understand that ifshc Wilding
s not currently haw•renanL marsltl,my OmPouihility m anti fy the asupant of Wemerneitswhi mug tom oases o ,Ce6reto 10, pgey. Signature of Applicant Date
ns ala gem f pate All roof coverings to be Class "B"or better