04050126 CI'FY OF CUPERTINO
B ,I
BUILDING DIVISION PERMIT C0NTRACTR
OaINFORMATI0N ..
BUILDING ADDRESS: PERMIT N0.
HEMANTH KANEKAL/ POORNIMA AYA 04050126
OWNER'S NAME: PERMIT ISSUE DATE
E:
SANITARY OL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
y
ea LICENSED CONTRACTOR'S DECLARATION
'y w C 1 hemby affirm foul
am licensed under pmvisiuna of CM1apmr 9(commencing Job Description
Zw with Section 70tH)of Division 3 of the Busineaa and Professions Code.and my license is
in full farce and effect,
.Eli License Class Le.x ADD 1014 SQ. FT. (MS4'VA
ATHRM &
I1=w Dam Contractor'SDECL LIVING RM/KITCHEN) �
ARCHITECTS DECLARATION
Z,O<c.
IundcrsunJ my plans shall he used public records
3 c.t; Licensed Professional
Ari
OW HER-BUILDER DECLARATION
I
1 hereby affirm that I am exempt from the Conaaeaor's License Law far IM1c ?0 as
000 following reason:(Section 7131.5,Business and Pmfessinm Code:Any city m county oag
Xm II- which"teres a permit to eenstNeL a1Kr,improve,demolish, repair any intercomV
y—'^ priorm its issuance,also re ices the applicant for such Permit to file a signed statement
-Z< that he is licensed pursuant o the Provisimrs of NC Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Va 3�°�973
,t—m (commencing with Section 7BPU)of Division 3 of the Business and Professions Code)or
Of N S Nal he is exempt Ncmfaom and Ne basis for the alleged exemption.Any violation of f
Section 7031.5 by any applicant for a permit subjeces Nc applicant to a civil Penalty of APN Number - Occupancy Type
not mom Nan rive hundred delta.(5300). r
E]1.as Owner arms property,or my employees with wages as their sale compensation. 36203017 . 00
.
will do the work.and the suuclues is not larded or offered for sale(Sec.7014.Business
and Prefcasim.code:The Contractors License Law does not apply to an owner Or Required Inspections
property who builds or impaaves Hereon,and who comasuch work himself or through his
Own employee,provided that such improvements are not intended or offered for sale.If.
however.Ne building or improvement is sold within one year of completion.the owner.
builder will have the burden of proving that he did not build or Improve for purpose of
aam.).
I,as owner of the pmpertY,am excluxivcly connecting with licensed contrsemrs la
C am Ne pmjct(Sea 7044,Business and Professions Code:)The Contractor's Li-
came Law docs not apply to an owner of property who builds or improw3 daemon,and
who contacts far such PrOhcu with a comntor(e)licensed pursuant in the Contractor's
License Law.
1 am ea.mpt under sec .B&P�C�`,do��m,ason
Dwaca�!/1 r1 Ia. CI_
WORKER'S COMPENS O�1 NUlc_LAKTiq ON
1 hereby af0rm under penalty of perjury ore of the following declarations: .
have and will maintain a Cenificam of Consent to self-insum for Worker'sCumpcn-
ion,as provided for by Section 3700 of the Labor Code,for Ne performance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,as required by section
1700 of Ne labor Code,for Ne performance of the work for which his permit is issued.
My Worker's Cam pen cation Insurance Cartier and Policy number am:-
Cartier: Polity No.:
CERTIFICATE OF EKEM"TON FROM WORKERS'
COMPENSATION INSURANCE
(Thu section recd not Mcompletcd it the Permit is for one hundred dollars(310(1)
,it lesi)
I certify Nm in the perrmmance of the work for which this permit is issued,1 shall net
employ any person in any foreman M to become subject a the Workers Compensation
Laws of Caliromia.Data
Applicant
NOTICE TO APPLICANT:If,afmr making this Cenificae of Exemption,you should
become subject to the Workers Compensation provisions of Ne Labor Code,you mors
.�Z forthwith comply with such Provisions or this Permit hall be de.mcd revoked.
Z O CONSTRUCTION LENDING AGENCY
PIneahyair,.that there is a Construction leading.,a,,I.,Ne performance Of -
a the work for which this permit is issued(Sec.3(Y97,Co.C.) _
(S) Q Larum,'s Nam.
G Tendcri Address
D Z
U C) I certify Nal 1 have read this application and sure dust Ne above infmmariun is
Iy Career.1 agree to comply with all city and county ordinances and state laws mating to
0U building Conawetion,and hereby•uthnrivn apresentatives of Nis city to curer upon the
W ahovomcnlioned property for inspection purposes
F a (We)agree to save,indemnify and keep harmless Ne City of Cupenino against
rn liabilities,judgments.casts and expenses which may in any way aemuc against said City
U? in APPhis permit.L CANTof the STANDS
eUNDERramong of IAND WILL COMPLY WITH LL NON-POINT Issued by: Date
SOURC REG CATIONS.
L BC1 Re-roofs
g awe APVIicaHAZARDOUS MATERIommithe ALS DISCLOSURE Type of Roof
Will the applicant or future building occupant ausm or handle hvaadaus material
as dcfoud!by Nc Cupcnina Municipal Codc.Chapter 9.12 and em Hcalue and Safety
Codc.Silvan 255321a)7 All roofs shall be inspected prior to any roofing material being installed.
Win the applicant or furubuilJing occupam tau equipment car devices which If a roof is installed without first obtaining an inspection,I agree to remove
nO.amnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
tri..
OYcsNu
I have read Ne h reardaus mamrials requirements underClopmr 6.95 of the Califon
niceHealth&SafetyCode,Ser:6uns25505,25533and25534.1.n&c ndthwif Ne Wilding
Docs not cumen0y have a¢ran that it is my msponsiM1ility w nntily Nn ocupant of the
rcy mmenawmm�muatbem paiorulmacecerace_ NOcamor .Open Signature of Applicant Date
Or a.maria4d agent L ,a All roof coverings to be Class "B"or better (///