05070124 CITY OF CUPERTINOy 7777M777;777777
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BUILDING DIVISION PERMITSCONTRACTQR�INFO ATION ;
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BUILDINOADDRFSS: SANJEEV SAHNI ` PERMIT N0.05070124
6733 CLIFFORD DR
OWNER'S NAME: PERMITISSUEDATE
SANJEEV SAHNI 12/06/2005
E; SANITARY NO. CONTROL NO.
ARC HITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUM0B 0MECH
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LICENSED CONIRACIOR'SDECLARATION Job Description
1 hereby.M.Out 1 am Ilanad under provlaaslom Chapter 9(commencing
with SeNon]Oflll)of Divialon of the Budnru std Perfections Cade,entl my Iicenso u
a� in ranramanda �n 8201 ADD-LIVING RM/KITCHEN/PORCH/BATH
z Llcan I tic.g A o
Dam Contractorj'J(gWAa amtNa✓l Ve 10531 REMODEL-FAMILYRM/3 BEDRMS/2 BATHRM
ARCHITECTS DECLARATION OFFICE
1 undcmand my plans&lull be used u public records
tow Licensed Professional
3 OWNER.BUILDER DECLARATION
I hereby Ali that 1 am exempt from the Comment's License Law for the
02 following w1,an.(Section 70 Business and Proressiuns Cam:Any city or county
II(ri which requires a permit In construct,alter.Improve,demolish,or repair any structure
prior W its luumtec,elan require the applicant for web permit to file a signed statement
�zFF< that be u llamad purwam m the provisions of the Comment's List Las(Chapter9 Sq. Ft.Floor Area Valuation
d� (commencing with Section 7(00)of Division y of the Burinen and Profasiom Coal or $281873
a that he is exempt themfmm and du basis for We alleged exemption.Any violation of
Section 7071.5 by any applicant for a permit subjects the applicant e a civil penalty of APN Number Occupancy Type
not more mm five hundred dollen(ML
❑1,u owner of the pmpwy,m my employcu with wgas u mob mlc comNnution,
will do the work.and thaatrocture la het intended or offered fmsde(Sm.7044.Burirca& 88
Required Inspections
and profession.Cade:The CanuacmYa Liana Law dote not apply to an owner of q p
eaywho ulMoorlmpmwuh mmchwark hn through his
own employers.Provided the such improvements am Ammutation confirmed
fm uln If.
however,Ne building or improvement is mid within ore yeti of c prove for
Ne owner.
of
builtler will have tiro burden of proving that he did not build or Improve for purpose of
ask.).
❑I,u owner of the property,am exclusively contracting withlicensed contractors m
construct the project(Sec.7014.Bwlneu and Professions Cade:)n is Contrator's Li-
come Law dao not apply in an owner of propery who Wilds at Improves the con.and, /
who contactsfar such pmjecu with a cantrmmr(s)licensed pursuant In We Controt
License Law. /
❑I am exempt under See. ,B d P C fm IN.anon
Owner Dam O/
WORKERS COMPENSATION DECLARATION 1!/
I hereby afNm under penalty of perjury ane of me following declarations:
w and will mdmnin•CeNfialo of Consent m self-insure for WarkoM1 Coupon.
A.u provided for by Section 3700 of me labor Code,for the performance of the
work for which this permit ie issued.
❑1 have and will ted,far Wmke(o Cance of the w Insurance,u required by Sectiond.
My of me labor Code.foe l performance of d wort ferwhicnumber A : permit to lewd
My Workets Compensation Insunmx artier and Policy number ant:
C.Mler�� Vltx, Policy He.:
CER7IFICATE OF EXEMPTION FROM WO ERS'
COMPENSATION INSURANCE
nissectson need ant kmmplcwd If the permit Is foram hundred callan($lip)
or M.)
I certify that In me performance of me work for which this Permit is issued.I Nall nm
employ any Noon in my mother an As At become subject to the Warkerf Compensation
Laws of Cdif.asm.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject m the Worker's Compensation provisions of the labor Cale,you a"
,J D foMwith comply with wch Parisians or this pease t shall be thermal marked.
CONSTRUCTION LENDING AGENCY
(ti IMreby al that then iso construction ending agency for the performmm of
(ti the work for which this Manor Is issued(Sec.0097.Civ.C.)
GQ Lends/s Nurse ,
Z)z Iande'.Add=
U Q 1 caddy that I have read this application and mate that the above Information is
gy Pcounter.1 agree in comply with all city mal county committees and mute laws milting m
C)U building eonwu,tion,and hereby wmorism represenutiws of this city to color upon me
f-0 .hove-memimml property for Inspection pugroses
(We)agree to sew,indemnify and kap harmlm the City of Cupertino against
C,) liabilities,jusimidA,thou and expenses which may In my way name against old City
V 7 in con unmoorthe granting of this fermi&.
Fl APP 1 NT,,,,QQQQ ERSTANOS AND ILL COMPLY WITH ALL NON INT Issued by: Date
SO R RIQrI TIONS. I Z/(/ !v
XX I J Re-roofs
Sign afA li Data
S MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building oceupmt sore or handle harardaho mamrid
As defined by tie Cupanim Municipal Code,Chapter 9.12,and the Haim and Safety
Cade.Seed..255E2W)] All roofs shall be inspected prior to any roofing material being installed.
❑Ym l�
Will tie applicant or future building oaupanl sea equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
hayardous air comaminanm As defined by the Bay Arca Air Quality Management all new materials for inspection.
.ict7
C Yes awo
I have mad the huallohomalorialsteyuiremcras undo rChap es6.95ofthc Cables.
a Safmy ,Satires 25505,25533 and 21554.1 undcamnd thin lftie Wilding
d at Iran a tented,that It la my ponsihllity m naul'y,the occupant of me
nim wi abemelprior tolaw of.Ccnificeloar u Signature of Applicant Date
l2 0 o Orth All roof coverings to be Class"B"or better
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