01050202 CITY OF CUPERTINO
nUILDwc DtvtstoN PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO. ,
1140 ELMSFORD DR CUPERTINO Pi ummion - _
OWNER'S NAME APPLICATION SUB DATE
SHIVA RAMESH 10237
PHONE: - - SANITARY NO, CONTROL NO:
O
t�r Z ARCIIITECT/HIJGINEER: BUILDING PERMIT INFO
t m= BLDG ELECT PLUMB MF.CII
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Z S y'O Z_❑ LICENSED
CONTRACTOR'S DECLARATION Job Description
1 hcrchy oICnt am licensed pmvisions of Chapter 9(commencing
F< �w wiN fa,once an1nf Divininn3 oftha lluvinessand rrnreasimsCmle.alta lay liceltec .
K Y � win fall uof,tori er(cd
C�< Dole
(, '3tp Lie.'win /e 1, 200 SQUARE FEET OF WATER SERVICE
3 y Dae —ll—sl� Contree ARA
ARChop he u"SDE CLblic re ori
1 unJcremnd my pinnr shall he nncA us public rccarJs
p O Licensed Pr,fcssional
OWNER-BUILDER DECLARATION
=' 1 h by infifirm h I 1 am escorts fircrat the Contractors L Law for the -
dG II g (Serino 7031....Business I Prolossionv,Cool Any city or county
❑ wl I q perm n n, i :dt 'cop 1 mol h ri p ny umnurc
3 m
prior to itse,al.so req the applicant tormch pemut to file a signed statement
that he is licensed preirsI to they isi of Contractors LLaw(Chapter9 Sq. Ft. Floor Area Valuation
(commencing arun Sectlan 7000)of Division 3 of the Bi arevv,and Pmfessi,ns Code)
' ,,met he is asempt there tion and,he ham,for the alleged,xc oplion.Any Awhrioi
,f Section 7011.1 by any appl team for a permit subjects the applicant to civil Penally
of not mate than rive hundred dollars($500). APN Number Occupan
MP
01,as owner of the proi or my employees with wages as their sole compensation,
will do the wore,and the xlmen,m is mol Intended ,,affect]rim sale(Sec.7044, -3620901
�2eg11Ced Inspections
Business and Professions Cale:The Contractorm s License Law does not apply an
suns,of pmPcny Who builds or improves t rromm,and who does such work himself
or through his own employms.provided that such impr,vemcmn are not intended or 103 — UFER
offered for sale.If,however,the building or improvement is sold within one year of
amiplmmn,amawaer-hnBder will have tire bumlen ofpmvhtg non lie did nail build or 1.0E — SEWER 8 WATER
Improve for Purpose of sole.). - '
01,asneroflbe pmpeny,ame¢lmively conmtcting mm
with licensed emncrsm 507 — FINAL PLUMBING -
construct he pajec,ISce.7094,Bminass I,ad Pmreasi,ns cam:)The Comramo2s
License Low does not apply to ua owner of propany o1,hands,,improves pattern,
and who contracts for such projects with a contrannr(s)licensed pursuant to the
Contractor's License Law.
01 am exempt under Sec. ,B&P C for this mason r� -
Owner Date
WORKER'S COn1PIiNSA'110N DECLARATION illi— u
Ihi effirt under pevallynf perjuryonc coffee following dermaliaw: B 8001
• ❑ 1 have and will maintain n Curillcaie of Consent m self-innate for Worker's JUL U L
Cmnpensatimt, as provided for by Section 37(X) of the latah Code, for the
performance of the work for whkh this permit is issued. BUILDING ,
0 1 have and will maintain Worker's Compensation Iasuruncc,as required by Scction
3701 of,he Labs Cale,Iia the prdonnunce of the work for which this penait is
d My W tkers Compensation Insumntt carri1er tand Policy nnnmGher ort:
P' try Na;y"nZ03i 1
CliRITFIG ONO IiXIiMI'T'ION 1'RQM1f WOI1KIiR5 '
UMI'F.NSADON INSURANCE
(This.section need not he completed if the permit is for one hundred dollars
S1 Bolton less.)
1 curt fy that in the performance of the work for which this permit is issued,1
shall not employ any person in any manner so as as become subject to the Workers'
Compenesalum Wws of California.Dam -
Applicant -
NUfICE TO APPLICANT:If,aper omking Ibis Cmifwle of Earraption,you should
Z 0 heanne subject m the Worker's Compensation provisions of,he LnMir Cale,you must
leotards comply with such provisions or this permit shall IN,deemed mvrAN. .
CONST RUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency fonbe performer.
if the work for which this permit is issued(Sec.3097,Ci,C.)
LQ IsnJds Nan.
.7 Z Lender's Address
1..) 1 ten ify Ian(I have read this ami colon mid erne that the above InRmnai,n Is -
Iis Fa correct.1 agree to comply with all city and county onlinances and state laws relating
0 (, to building construction,and hereby authorize representatives of this city to enter upon
} (y I the aMve-mention ori pmpeny for inspection purposes. t
�.I its _�We)agree it,save,indemnify and keep harmless the Cry of Capetian against
f-r (Zli, IWe"Imdgnante.carts cold expenses which may In any way accrue against said
ly m em sat enc``of t e gmnhng of Nis permit. o
r SUPLICA T . 'Dg105 NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 1�-►-� Date �7 '— �"
/U
Signature m Ann'.nticaam,m Date �— Re-roofs -
IA=D US MA'I'ER1ALS DISCI.OSU RE
Will appllc r re building deutan atm or handle hmurdous material Type of Roof
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7 _
°Yes 91ko All roofs shall be inspected prior to any roofing material being installed.
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
til hammers air contammams as defined by NC Bay Area Air Quality Maagermad
District.' all new materials for inspection. Applicant understands and will comply with
°rc` all non-point source regulations.
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safep,Code,Sections 25505,25533 and 25534.1 understood that
if fhe,gswJr,Joe,no, , ybaseumnun.lhnt it is my feswnrvi hi l'dym anti lY the s
or pont of c req,' Erna rich mast he met prior m issuance nr a Cerm icat of
Os vpancy.
^3t C-) ( Signature of Applicant Date
Own amh,ri,rd.,,her, Dae All roof coverings to be Class `B"or better
OFFICE