02080106CITY
BUILDINGON
UI PERMIT
CONTRACTOR INFORMATION:
BDg�I��p$6cBgAEET�TE AV
AMITABH SHUKLA
PERMIT NO.
tilyl l �AISY1 SHUKLA
APPLIC 5 CSN/YI)Al5 O O 2
PHONE:
SANITARY NO. CONTROL NO.
zz ARCHITECDENGINEER:
BUILDING PERMIT INFO
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BLDG ELECT PLUMB MECH
L= u r- i I"--1
z LICENSED CONTRACT'OR'S DECLARATION
JobDescri Iron
p
usiti.of Chapter 9 (comencing
o I hereby affirm that I am licensed under prm m
DEMO POOL
with Section 7")ofDivision 3of the Business and Professions Code.and mylicense
.a tinter force and cReer.
,I is
IFI fit6 A Y F.G''11
U Licenu Clasx Lie. 4
9 NC /�\ �Ym �ad1
Date Conmacmr
-
understandaARCHITER'SDECLARA
S 1 understand my plans shall be d as public amends
AUG 2 3 2002
0 Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby afTum that I ore exempt from the Contractor's License law for the
BUILDING
a fallowing ream.. (Si 7031.5. Business end Pmfcsxims Cade: Any city or county
$1500
O which minims a permit to consumed. alter, improve, demolish, or rtPan any structure
00 . prior to its issuance, also requires rhe applicant for such list.., to rile a signed surement-
..7777 _
- Watt he 3l avicd puisuWttV die pio vont of the Cdome ops Liana law lChapter9
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Valuation
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(cotmimne rte withsat ]OW) fD'vismn3of the Business and Professions Cade)
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C {-;Z L '. zv. `_. A -I; t_la c. S�
or dot be ss P,therefrom and the bass for the allegal uempdon Any v olauon
of Saturn ]031:..
11by any applicant for a permit subjects Ne applicant m a civil penalty
ofnatmom"..IseIt red .E.( ',
NO ABL'dT3ii�i�d INSPECT
ONS, t: •' Occupancy Type
1, as owner of Ne property, of mY employees with wages as their sole compensation,
w It do the work: and -the'swnure'Is not intended or'ofemd for sole (Sec: ](344.7
\, s
Required Inspections
'Business and Professions Code: The Contract.,', License Law does not apply t. an
owner of property Who builds or improves thereon, and who does such work himself
or through his own employees. provided that such impmvemems arc not intended or
off df sakehowever, the bu ldin8 p emeni is abld within one year of
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completion, the owner builder will have the burden of proving that he did not build or
improve for purpose of ms.).
,
❑ 1 of the property. exclusively contracting with licensed ontract rs to
, - -`_".
_ construct the project (Soy 7044, Business and Professions Cade) The Contractor',
,.
License Law does not apply to an owner of property who hullds or improver thereon.
:. ..and who,contracts.for such projects. with a contractors). licensed. pursuant. to the
ors License Law...
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E] I nor
_ ❑lam wear ,unJer Sates: � � ';B&PC for this mason
,.,
Owner'`"_„]�' _ Doc
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of Me following dcclamtium
❑ I have and ,it totintain -'Certificate of Conse,n ui .ulf-insure for Worker's
C.ma,m fund, m powided•fnr by Scaian 37W of ,he Labor Code, for the
- performance of the work I fur which IN, permit, is Issued..,,
❑ 1 have and will mnimdin Worker's Compensation In'.sumnce, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is
issued My Wmkery Compensation Insurance carrier and Policy number we
..... _ ... ,......- .,
Cazrer, i. 'I.,f 1 - ss'.`Policy No.
CERTIFICATION OF FXEMPTION FROMwORKE RS'
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t iy:` J -i. irta2"k fil't Si!1_}v°'t' i -
._„_...,COMPENSATION, INSURANCE
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'(This scc,iod need not completed if the permit is for one hundred dollars
115100)orlcss0
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1 .fY Ne, in the pcAo ate o(N kf h M1M. pe l J 1
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all t employ y R Y man t bee bn l t ,h W rken
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Compcnsato�{ of Calif rtlarpate
'Applicant
NOTICF.TO AYPLIL If after milt N.
g,Certificate of Exemption you should
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become subject m,he Workees Compensation provisions of the Labor Cade, you must
� f.nhwiN comply with such provhions m Nis permit shall be deemed revoked.
it CONSTRUCTION LENDING AGENCY
I hereby affirm that Nem is o conswction lending agency for rhe peRorma,ce
'
of the work for which Nis pc,mit is issued 1Sec. 3097, Co. C.)
,
: -Lender's Name'. •`.. .•. _ _. ...�_
N
..1 certify that 1 have read INS application and sure Nat the above information is
correct 1 agree ro comply with all city and county ordinances and stare laws relating
I. Wilding consrzue,iom and hereby authorize representatives of this city to enter upon
the above-mentioned property for ublPsoom purposes.
(We) agree lo save. indemnify and keep harmless the City of Cupertino igsinst
1 liabilities, judgment. cost and expense, which may in any way accrue against said
City in consequence of the granting of Nis pnmiL
'
APP�r�,3XT UNDERSTANDS AND WILL COMPLY WITH ALLNON.POLNT
Ry,Gucarlo5sr.,
Issued bye
�t,�pzp ., ,,
Date
9s¢nature of mindcontmcte,'.' ' .. Date'
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
.tom' Will Ne applicant of future Wilding occupant same or handle hazvJouz marenzl
-.Type of Roof.
as defined by Ne C.1ifin. M n sipal Cada Chapm, 9 12 end the Health and Safety-
CodeStrom 25532a) -
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.. iC7Ns
9'x r,^, >><'1 'ts r Lkl'1{k^ l
wu N apphua r o ret Wilding ea
mot,
Al] roofs shall be.3nspected pnor_to any roofing material being.installed. -
sto
emth0Y re ore an,. as def neJ by the Bay Arcn A Quality Management'
ay'Ama i tde age
If a roof is installed without first obtaining an inspection; I agree' to. remove
Dist r
E) No "_
,,,, all new materials forregulations.,',,,.,,,, inspection. Applicant understands and will comply with
.
all non -point source regulations
1 have mad rhv h dous materials requirements under Chapter 695 of the
,,, I
California Health & Safety Code, Sections 25505 5533 and 25534 1 undersmnJ that.
if theIdi, does nm current Iy have a Ision , thin 'I II yraP:'bl ty in rody he
dee r q c er which dib r , .ms mu ate of
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Signature of Applicant-,._...._:.. Date
All roof coverings to be Class `B" or better
i-ositer or author zed a em
g Dole
........ ..... OFFICE ... . ....