04110026 CITY OF CUPERTINO ''" '"M%"s' a '' ser "" ' � '
BUILD'
DIVISION PERMIT - '��CONTRAC�TOR+INI+'ORMA` JO -
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BUILDING ADDRESS: PERMIT NO.
RAJESH SHAH 04110026
W AM PERMIT L90UE DATE
]NE: SANITARY OL NO.
ARCHrIECrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+Dioo LICENSED CONTRACT'OR'S DECLARATION
I hereby affirm that I am licensed ander previsions of Chapter 9(commencing lob Descrlpl
i ' wire Semiun TGMI)of Division Sof the Business and Professions Codc.and my license is
a 6 6 in full force and effect.
License Class Lic.a REPLACE WATER HEATER NOVT1/'
Dan-Contractor ARCHITECT'S DECLARATION _ O `G LJ
OOT
¢ I undersand my plans shall W used re public«cords -
er n
'' Licensed Prufcsu M cs
.P II II D (�
ig OWNER-BUILDER DECLARATION U \\\VVn1
I Wmby allinn mal I am exempt Trent the GOninClarS License Law for the ILII
n ea
mO following rson.section](1313,Busmeas and Pmfeetlun Code:Any city or county
CS
x m IL which requires a permit In emistmel,site,,improve.demnlLsh.ar repair any structure
prior to its issuance.also expona thc applicant for such permil to rile a signed statement
x that he is licensed pursuantto the provision ofthe Contractor's Lianit,Law(Chapter 9 Sq.Ft. Floor Area Valuati
yt-m (commencing with Section 71300)of Division 3 or the Business and Profession Code)or
y
that W is exempt Uu mfrom and the breis far ate alleged exemption.Any violation of
Section 7031.5 by say.pplicant for.permit subjects the.pplicant I...wil penalty of - ,p.p�t,hh� er Occupancy Type
not mom man Ove hundred dollen($500). 3 e 7 Z'1 v e.s3 0 Q
0 I,as Owner of the property,or my employers with wages u their sok compensation,
will do the work,and We Slrumure is not intended or offered for Sale(Sec.7004,Business
and Profession Code:The Conaaewrs Liarce,Law does an,apply to an owner of Required Inspections
property who Wilds or improves thereon.and whodocasmh work himself orthmugh his
Own employees.provided mat such improvements are not intended cautioned for sale.If.
however,We building or improvement is sold within one year of completion,the owner
builder will have We burden of proving mar he did not Wild or improve for purpose of
sale.).
❑I.as Owner of dm property,am exclusively contracting with licensed contractors in
consumer We project(See.7W.Business and Pofasvom Code:)The Contractors U.
enc law does not appy to an owner of property who Wilds or improves thereon,and.
who contracts for such projects with a comosc or(s)licensed pursuant o the Contractors
License Law.
TAI am exempt un'der,SoB A P C far thio mason
am
W 'S COMPENSATION DECLAR N
1 hereby affirm under penalty of perjury one of the following declarations: '
I here and will maintain a Certificate or Consent to self-imure for Workers Cooper-
.
ooper- _
Game
as provided for by Section 3700 of We labor Code,for the performance of the - ..
work for which this gamil is issued.
I have and will maintain Workers Compenssrion Insurance,as required by Scedon
37W of the labor Code,for We performance of me work for which this permit is issued.
My Workces Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(Thissee,mr,need amt W completed if de permit is far..hundred dollars(SIM)
m less.)
1 certify mol in perfamrma of the k for which this permit is issued.I shall not
emplOyany Peron anYL.�r�Mrpct syTtW Worknos Cmnpensation
Laws of Calif 1}D 11
Aplatinum.
N ICE TOA PLICmaking his Certificate of Exemption,you should
Weo sohNet to the Worker's Compensation PoOVi3lom of Ik labor Cndc,you must
.J O foMwh nmp1Y With such provisions or this permit aM1sll W deemed rtmkcJ.
zCONSTRUCTION LENDING AGENCY
'e.r0+ Thereby affirm thmthem is a construction lending agency for the performance of
ai 7 We work for which this permit is issued(Sec.3097,Civ.C.)
f[7 Q Land is Name
Iander'a Address
tJ Q I certify Nu I have rad this application and sate that the aWve infomuitim is
LT. F comma.I agree to comply with all city and county ordinances and sure laws relating to
0U building construction.and hereby authorim representatives of this city to enter upon One
aWvc-menu med property for inspection propose.
y (We)agree m save,indemnify and keep hornless the City of Cupenino against
TA Iiabiliues,judgments.cases and eapenus which may in say way aane agaimtcoal City
his
U Z APPLICANT UNDERSTANDSisequent.or We CombofIAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
LS. fo i I Ot Re-roofs
mreof Appli omaracmr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant smrc or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(e)? All roofs shall be inspected prior to an roofing material beim installed.
❑Yes (�No P P Y g g
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
iI hamrdous air contaminants ex defined by We Bay Area Air Quality Management all new materials for inspection.
mlct?
❑Yes 'k NO
I have toad the
car nus mawrials requiremcnta under Chapter 6.95oftheCalifor-
amHeahhAt Salcycode.Secuan 25505,25533 and 25534.1 underrmd the if the Wilding
does not cumcntly have a tenanL that it is my rc+panibility in newly We oc upanl of We
m4ainmcos which moat he at prior to menswear.cerdnamar OC,paney. Signature of Applicant Date
1 i 0 o W All roof coverings to be Class"B"or better
Ow fur authorizEBagcnl— Da