06010145 CITY OF CUPERTINO °'
BUILDING DIVISION PERMITfC0NT, ACTOR NF,FRMATI91 £
BUILDING ADDRESS: PERMIT NO.06010145
10222 BARBARA LN
OWN F)R'S NAME: PERMIT ISSUE DATE
HIMANSHU BAXI 04 /14 19,006
SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECHO
loo LICENSED CONTRACTOR'S DECLARATION Job Description
las I hereby affirm dol 1 am n licensed under Provisions of CNPW 9(Commencing
to Section 7")of Divisloe 3 of dm Bill.and POICu amm Code,and my hcesse,Is
is(.11 fnroe Out effect. �D2 fj4Ci ADD 556 ' -LIVING RM/BATH/BEDROOM
:�? Liceno el Lle.•
qqq Dam u t Contractile, fya3 REMODEL 1780 ' /RELOCATE KITCHEN
3 ARCHITECTS DECLARATION
I I understand my pbn+hall W used an public records
,8 ti Licensed PmfesionaI
OWNER-BUILDER DECLARATION
qy i hereby aRrm Not I am exempt frum Me Contractile,License Law for the
LOO following mason.(section 71313.Business and Profession Code:My city or County
.i$ff Which mquims•Permit to cnnaraL ALdemom
ttr,improve.demolish,or pair any sum
ucm
_y Sus prior to it issuance,ALSO require,tie applicant for such permit in rile a signed sutmem
< that he is licensed pursuant to the pmvialon or to Canuoctur's U..se Law(Chaper 9 Sq.Ft. Floor Area Val$9918524
959 (commencing with Section 7000)of Division 3 of the Busimeuand Professions Code)or
Nal K Is exempt dedefrom and de bub for Ike alleged eaemption.Any vloladon of
Section 7031.5 by arty applicant post permit subject the applicant M a Civil penalty of AFN Number Occupancy Type
trot mart Mao rive Madmd dallva(SSW). 35912020 . 00
1,u hewer of civ:p.atruc a mY "offered
o wages or Me'u sole compenuless
will dethe wroh.ander WConthoure bOutrmmnense LA a does r We Out
7044,BusinOwner of Required Inspections
and PMeseiome Code The Contractors License law floes oro apply lf an ower of q P
property Who builds o i ed Mitsui m Mmes who donsuch in work himaelre through his
Own employees,provided improvement
Improvementtae notea:IMWoroRemdfor axle If.
however,Me WildingvMis o Improvement t ustd within aro year of c prove for
Mc owe ur-
of
builder wIB have Ue bt.den of proving Mat k did Out build a improve far puryaxe of v
tale.).
1,at owner of Me Property,am exclusively...munal,was Earn. Cosrnnars M
consumer she PmKct(Sec.7044.Business sent Profession Code:)The Contracmh Li-
eemee law does not apply In an owner of property who builds or Improwa Memo.,and
who contact for such projecta with a conuacmr(s)licensed Putman,in cite Contractors
License Law.
❑Iameamptunder Sa. ,1181Pchuth4roam
OwnerDECLARDat
WORKER'S COMPENSATION ATION
L hereby sfRtm under penalty of perjury,un W the following(ecluWmrs
I ham and will maintain a CeniOa s of Consent to self-b tum for Workers COMIX"
nation,as provided for by Section 37W of the Labor Code.fa the performance of the
wart for which this permit is issued.
❑I ban and will evaluate Workers Compensation Insuane,u required by Section .
3700 of the Inbar Code,for le performance of the work for which this Permit is himuL
1 My Wmars Compeuadon hrsutauzac�arrier and Policy number am:
Cartier. 51-A r—t,NY Policy Nolo;zu W q—2
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE y
Crisis section coed notheeampkmd If the permit is forenc hundmddollan($100)
or less)
1 sudyi Met in tis p"ficumena of the Work for which lis Permit is issued,l ulmll rat
employ anypetann in any mennrso t M became subject to the Workers'Canpetwtiao
Laws of California.Dat
Applicant
NOTICE TO APPLICANT:If,after making this CeniRcae of Exemption,you should
become subject in the Worker's Compensation provision of the Labor Code,you mon
O forthwith comply with such provision or this permit shall In deemed mw hind.
z„ V1 CONMUCT10N LENDING AGENCY
F-' I hemby affirm MU Memo aeonmeti.w lending agency for to performance of
(Yv> cit work for Which this permit is intent(See.3091,Ci,C.)
Wel,Q Lenders Name
z Landers Address
U0 I certify that I have mad this application and rut that Me shove Info mubun is
ILf~' cones.I agree to comply with all city and county ordinances and suite laws misting m
C) building Conviction,and hereby authodR mPmaentliveS of this City to enter upon dM
M shove-mcnduned progeny for inspection
xperi o.purposes
(lie)agree to an,indemnify and kap harmless tie City of Cupertino against
fZ in Consequences WAm and experience Pawhtch may in anewYsarueaNn+,mid City
Uz A APPLICANT
of Megmndngof lisDWIL Date
t—t APPLICANT DNDERSTA DS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR EOULATIO
s Re-roofs
SlgmuurCofAppIMma ontraaa I Dat
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will f appllam or future building oaupulaore ahandle harudou mamrind
u defined by the Cupertitm Municipal Code.Chapter 9.13.and de Health and Safety
Code,Seaa.ss533ca)? __// All roofs shall be inspected prior to any roofing material being installed.
[3y" elNe
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant Or future building Occupant use equipment or devices which
k banrdous air commitment a de0ncd by the Bay Ara Air Quality Management all new materials for inspection.
District?
❑Yes
1 ban mal the haraNtwsmaterials requirement
SafetYCaM,Seem=25505,25533 and 25534.1 understand thalfde Wilding
does not currently have•un that let t my msponibuly ro notify the oaupent of the
myuimf�'ta which muR normissuana ofa Cenifmatof cupany4 Signature of Applicant Date
"''� l��y !VG All roof coverings to be Class "B"or better
Owner or ahhori.il agent Dat'