01050021 CITY OF CUPERTINO .
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADUR€l0651 CARVER DR: BUDGET PLUMBING PERMITNO. 01050021
OWNHR'`NAMIJJONICA DOSHI 28695 ROAIdOF\E ST APPLICAI'ION S0ICrM1`/`001
'PHONIio (5.10) 303-7847 SANITARY NO. CONTROL NO.
a cc O ARCHITECTNNGINEER: BUILDING PERMIT INFO
w C BLDG ELECTPLUMS - MECH
Neaw .r=1
LICENSED CONTRACTOR'S OECLARATION
c.
` I hewn mom me,1 ant nsvnwd macs p g Job Description
got. hereby -will pions orcnntrrvndon,I ncln' P
:tw wimse<rnnmfndefect. nn3nnneBu,toes,amu•rnreun,naewr.andr°yIi001"° GAS,'LINE "REFIRGEMENT.
Y 3 J i.in full lass and street.
a histone Class Lica
x o d U Dote Conmmmr -
w 3 u vF. used
ARCOuDECLARATION
a
F-�•GS J d ypl staff
Il hr J 'public rccard,
f 25 C a..ai.
a p_q�j,pe p Licensed Y f OWNER SUILUFR DI Cl ARAI ION (^�j
6nw In by R a I 11f Ili C I' t :l Laforme V
r.7- following reason.(Swa 7031.5. .' P f,.' Code,Any city r r umy
O whmh acquires if penal to comuua,alter,improve,demolish,or repair any swmure
o. 'hal
prlorto its issuance.also require.,the applicant for such pernitto file a signed statement - -
matheitlicensee par..nam tome pro.i.mm of ntr Contractor.Liveme Law(Chapter e SQ- froFL Floor Area Valunnnw
(summered,with Section 7lgo)of uivi,ion Sof dhe Hware,.and Prnfeuinn •z Cody) olo
or flim he is exempt therefrom and ate basis for the alleged exempron.Any solation
of Section 7031.5 by any applicant fora prraii,suhjecdx the appllcem ata rail penalty
of mmmom than fi.c hundred dollars($500). APNN"beri049. 00Occupancy Type
°Luxus ncndmc p...Nny,crmy ionployee,wan wase-s as their role compensation, .
will do the work.and the suaourc is no,imended or offend for star(See.70H4. -
limary,,arta Ptnfe,inn,Cadw The Co rdra ,Liccnw Law does not apply m anS0c — F h'3��r-PL��t�}��i ENERGY
mr ul'pmpm,y who mild,ur improver thereon.and who doer such work himwlf
through h s own employee,-pmA,cyI than such improvements are nut intended er 506 — GAS TEST
offered lot salt.If,however.the building or impmvemem is sold within one Year of
imnnpletion,the owner-builder win have the burden of prm;ng that he did not beim or
prove fill mnpow of arae.). 507 — FINAL PLUMBING
°I.as owner of the pmpeny,um exclusively contracting with liccewd contractors to
Lam',the power(Sec,70.14.Bss usineand Professions C,de:)The Contractors
icense Law mw,not apply to an owner of property who ootids or imprvve,thereon.
and who contracts for such prei with a contru<tar(s)licensed pursuam to the
Connector',License Law.
.°1 um exempt under See. tt tit P C fur mi,reason
Owner Data
WORKER'S COMPEN.SAIION DKCI.A RAI ION- '
I hcwby affirm under penalty of perjury one of the following declarations:
❑ I bare and will maintain n Cenilicam of Corwin to self-insure far W..oar,
Compensation, a, providrd for by Section 37M of the Lata„ Crde, for ,he
hcrfurmunm of rhe work for which this penal t,issued.
°1 have and will maintain Worker's Compensation Insurance,a,required by Semon
3700 of the Labor Calc,If,,the perlormmnce of the work for which this permit is
mond,iffy Workers Compensarinn Inwrance carrier and Policy number we:
Carrier: Policy No, -
CFRI IIICA'I'ION OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
This,cction need nm If,completed if the penton is lira ons hundred dollm,
15100)or Tess.) ,
I eerily that in life performance of the work for which this pemtit in issued,I
shall not employ any proem in any otos..,eo as of becanm subjen to the Workers'
Compcn,mion Laws of California.Dae
Applicant
NOTICE I O API'IACANT:Il:suer reakno,fli s Cunlficala of Exemption,you should
nmc pe
ccosubject to the Workers Compensation pmvislen of ilia Labor Cade,you must
' C forthwith comply wish such provisions if, permit shall be deemed revoked.
Z .
F
CONSTRUCTION LENDING ice,agCY .
> Inkfar,lIch the m,.iry f is roned(Sec. lendinse.Cy roc he p<rrnmrmer
of me war k for which this pu,mit is issued(Sec.3097.Civ.CI
4 ❑ Lender:Nanta
5 Z 1<nJer'x Address
V O 1 certify he 1 have rout arts npplicalimi aad,l2le that the all information is
corwa.1 agree In comply with all city and county ordinance,and one laws relating
V to hoildingconswetion.and hereby authsmicmpre,emalnes ofrhi,cily toemer upon
�s W ma tthove-menaomIit pmpeny tot im'peainn purpose..
(We)agree m,ave,inden nd,i I keep hannle,me City of Cupertino against
VW liabilities,judgments,costs and expenws which may in any way acerae against said
Z City in cia,ce,encc al he pending at[,is permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
SOURCE REGULATIONS. Issued by: - Date
srgnamm of A,fi,ar vcmtm.clm Oma Re-roofs .•
HAZARDOUS MATERIALS DISCLOSURE
Will the applimew o,fume banding occupem save or handle ta,mous material Type of Roof
m defined by me Cnpcnino l4wicipul Code.Chapter 9.12,and the Heath and Safety
Cade,Section 25532la)p -
CYe, 0 N All roofs shall be inspected prior to any roofing material being installed.
Wll Is applicr,,,more huildingneevpont use equipmemor devicr,which If a roof is installed without firstobtaining an ins eCt10n, I a see IO remove
emit hmallous air swermirearoas defined by the Buy Arca Air Condit,Mm,agroeo b pegree
Don in? all new materials for inspection. Applicant understands and will comply with
°YsX °Na all non-point source regulations. PP _
1 e base read the hooe,,Code.
od. omen,2 requ505, emanr..socks 4.1 un 6.95 of the
Ctdie bailing does
al arrCll,hanclloca 25519at it is yrespoad 3q.lundcrsondtom
ifthebuildingdor,nn,currentlyich atmos,et it myresponsibilityaymificythe "
'Occup ni of the myulmmcno which mw,be nv prior a issuance of a Ccnificu rc,
Oecapamy Signature of Applicant Date
Ower or authorized agent Dace All roof coverings to be Class `B"or better
OFFICE
CITY OF CUPERTINO .
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADUR€l0651 CARVER DR: BUDGET PLUMBING PERMITNO. 01050021
OWNHR'`NAMIJJONICA DOSHI 28695 ROAIdOF\E ST APPLICAI'ION S0ICrM1`/`001
'PHONIio (5.10) 303-7847 SANITARY NO. CONTROL NO.
a cc O ARCHITECTNNGINEER: BUILDING PERMIT INFO
w C BLDG ELECTPLUMS - MECH
Neaw .r=1
LICENSED CONTRACTOR'S OECLARATION
c.
` I hewn mom me,1 ant nsvnwd macs p g Job Description
got. hereby -will pions orcnntrrvndon,I ncln' P
:tw wimse<rnnmfndefect. nn3nnneBu,toes,amu•rnreun,naewr.andr°yIi001"° GAS,'LINE "REFIRGEMENT.
Y 3 J i.in full lass and street.
a histone Class Lica
x o d U Dote Conmmmr -
w 3 u vF. used
ARCOuDECLARATION
a
F-�•GS J d ypl staff
Il hr J 'public rccard,
f 25 C a..ai.
a p_q�j,pe p Licensed Y f OWNER SUILUFR DI Cl ARAI ION (^�j
6nw In by R a I 11f Ili C I' t :l Laforme V
r.7- following reason.(Swa 7031.5. .' P f,.' Code,Any city r r umy
O whmh acquires if penal to comuua,alter,improve,demolish,or repair any swmure
o. 'hal
prlorto its issuance.also require.,the applicant for such pernitto file a signed statement - -
matheitlicensee par..nam tome pro.i.mm of ntr Contractor.Liveme Law(Chapter e SQ- froFL Floor Area Valunnnw
(summered,with Section 7lgo)of uivi,ion Sof dhe Hware,.and Prnfeuinn •z Cody) olo
or flim he is exempt therefrom and ate basis for the alleged exempron.Any solation
of Section 7031.5 by any applicant fora prraii,suhjecdx the appllcem ata rail penalty
of mmmom than fi.c hundred dollars($500). APNN"beri049. 00Occupancy Type
°Luxus ncndmc p...Nny,crmy ionployee,wan wase-s as their role compensation, .
will do the work.and the suaourc is no,imended or offend for star(See.70H4. -
limary,,arta Ptnfe,inn,Cadw The Co rdra ,Liccnw Law does not apply m anS0c — F h'3��r-PL��t�}��i ENERGY
mr ul'pmpm,y who mild,ur improver thereon.and who doer such work himwlf
through h s own employee,-pmA,cyI than such improvements are nut intended er 506 — GAS TEST
offered lot salt.If,however.the building or impmvemem is sold within one Year of
imnnpletion,the owner-builder win have the burden of prm;ng that he did not beim or
prove fill mnpow of arae.). 507 — FINAL PLUMBING
°I.as owner of the pmpeny,um exclusively contracting with liccewd contractors to
Lam',the power(Sec,70.14.Bss usineand Professions C,de:)The Contractors
icense Law mw,not apply to an owner of property who ootids or imprvve,thereon.
and who contracts for such prei with a contru<tar(s)licensed pursuam to the
Connector',License Law.
.°1 um exempt under See. tt tit P C fur mi,reason
Owner Data
WORKER'S COMPEN.SAIION DKCI.A RAI ION- '
I hcwby affirm under penalty of perjury one of the following declarations:
❑ I bare and will maintain n Cenilicam of Corwin to self-insure far W..oar,
Compensation, a, providrd for by Section 37M of the Lata„ Crde, for ,he
hcrfurmunm of rhe work for which this penal t,issued.
°1 have and will maintain Worker's Compensation Insurance,a,required by Semon
3700 of the Labor Calc,If,,the perlormmnce of the work for which this permit is
mond,iffy Workers Compensarinn Inwrance carrier and Policy number we:
Carrier: Policy No, -
CFRI IIICA'I'ION OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
This,cction need nm If,completed if the penton is lira ons hundred dollm,
15100)or Tess.) ,
I eerily that in life performance of the work for which this pemtit in issued,I
shall not employ any proem in any otos..,eo as of becanm subjen to the Workers'
Compcn,mion Laws of California.Dae
Applicant
NOTICE I O API'IACANT:Il:suer reakno,fli s Cunlficala of Exemption,you should
nmc pe
ccosubject to the Workers Compensation pmvislen of ilia Labor Cade,you must
' C forthwith comply wish such provisions if, permit shall be deemed revoked.
Z .
F
CONSTRUCTION LENDING ice,agCY .
> Inkfar,lIch the m,.iry f is roned(Sec. lendinse.Cy roc he p<rrnmrmer
of me war k for which this pu,mit is issued(Sec.3097.Civ.CI
4 ❑ Lender:Nanta
5 Z 1<nJer'x Address
V O 1 certify he 1 have rout arts npplicalimi aad,l2le that the all information is
corwa.1 agree In comply with all city and county ordinance,and one laws relating
V to hoildingconswetion.and hereby authsmicmpre,emalnes ofrhi,cily toemer upon
�s W ma tthove-menaomIit pmpeny tot im'peainn purpose..
(We)agree m,ave,inden nd,i I keep hannle,me City of Cupertino against
VW liabilities,judgments,costs and expenws which may in any way acerae against said
Z City in cia,ce,encc al he pending at[,is permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
SOURCE REGULATIONS. Issued by: - Date
srgnamm of A,fi,ar vcmtm.clm Oma Re-roofs .•
HAZARDOUS MATERIALS DISCLOSURE
Will the applimew o,fume banding occupem save or handle ta,mous material Type of Roof
m defined by me Cnpcnino l4wicipul Code.Chapter 9.12,and the Heath and Safety
Cade,Section 25532la)p -
CYe, 0 N All roofs shall be inspected prior to any roofing material being installed.
Wll Is applicr,,,more huildingneevpont use equipmemor devicr,which If a roof is installed without firstobtaining an ins eCt10n, I a see IO remove
emit hmallous air swermirearoas defined by the Buy Arca Air Condit,Mm,agroeo b pegree
Don in? all new materials for inspection. Applicant understands and will comply with
°YsX °Na all non-point source regulations. PP _
1 e base read the hooe,,Code.
od. omen,2 requ505, emanr..socks 4.1 un 6.95 of the
Ctdie bailing does
al arrCll,hanclloca 25519at it is yrespoad 3q.lundcrsondtom
ifthebuildingdor,nn,currentlyich atmos,et it myresponsibilityaymificythe "
'Occup ni of the myulmmcno which mw,be nv prior a issuance of a Ccnificu rc,
Oecapamy Signature of Applicant Date
Ower or authorized agent Dace All roof coverings to be Class `B"or better
OFFICE