05120053BUILDING DIVISION PERMIT
SURESH
1 hrtby affirm that I w Seemed easier pmviuom mCWpter Y (commemy
with Section 70Im) olT ivlsian 3 afdu: Budmssaml Profusom Code, ad my liceme 4
in full forca and affect
License Clan Lle, a
Dale Contractor
ARCHITECT'S DECLARATION
1 understand my plans Nall W used u public rtcort4
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am sump firm the Comractds License Law far the
following moon. (Saban 7031.3, Business and Professions Cade: My city or county
which requtru a Penis to commacL alhee Winona, demolW, or repair my somatom
prior In its issuance, aim mquima the applicant for such permit an Ole ashmd statement
than W Is licensed innocent m the provisions of the, Contractor's Liana Law (Chapter 9
(commencing with Soudan 7000) of Division 3 of No Business and Professions Code) or
Nat he is.emp Otmefmai and the basis for Lha alleged.mtytlm. My vioWfan of
Salem 7031.5 by any applicant for a permit subjecu the applicant to a civil Penalty of
not mart Nan Dw hurled dellars (.SS00).
❑ I,uawwarafdepapem.amyempla)mwm"vsud irwic mp=uon.
aid Prl wonCdsea he Cae4notstolesaraw d(mule(Sec. 70 l6, Budr of
and Pm(ualom Cade: The m mucor', Licenseand
who Law dam tot apply lf rt owner is
Own
property Wildamimprateach imps wmates wassuehwork wGffc or Nmugh his
own"r, the uipmMdr: I pr suchImPm id within am
our of orMferd(mule.if.
Wild. the WildingOr uimpmwmentistoldwithinam ill of mprove for
owner
Wilda will hew the burden of proving that k till not Wild are improve (or puryoa of
ale.).
❑ I. u owner of the property, w exclusively contracting with limned antra m a m
comment use, pmlat (Sec. 7016, Business ad Pmfudam Code) The Coowmors Li-
ccua law does Out apply to an tames of pmprnywho Wilde or impmw, Nemn, ad
wW contract for such pmjeeu with a contractor(s) accused! pmsem M the, Committees
(-lamas TAW.
❑Ism.QI under Sec Case
PC)fm�Nis/((�e,+u,+,aa^n
Ow�lJ %� r/_6;Due
1 Wreby affirm under penalty of perjury am of the following dec'lara come
I haw and will main Wn a CaNOcare of Consent m Self -imus for WotkersCormPen-
an, u provided for by salon 3700 of the Inbar Cade. fm the Perfarmen of the
rk for which this pemdt is issued.
1 haw and will maintain Wastes Compensation Issuance. u required by Section
D of the Law Code, For me performance of the wads for which this permit 4lwmd
Workers Compensation Imuran seri. and Policy numWr ate:
frOa alas wad act as, mmplemd Ude pewit is f ammemed dolens(SIM)
or leu)
I certify that In the perfoanurce of the work for which this permit 4 issued. I Nell ut
emplayanyperm many mane as W-=
- es ' ttoth Wmkus' ompmination
Laws of Califaegryil Dau
AP 111 _Gg og. /�c�
NOTICE'RYAPPLICANT: If, after making this Certificate of Eumptilin. you should
become subket in the Workers Compensation provisiore of the Labor Code, you muse
., fordwich comply with such provisions or this peh Nall domed roked.
Z0 rmW mev
� CONSTRUCTION LENDING AGENCY
PI hereby a0lrm eat Nem 4 a comtrucdon lending agency for the perfarmuec of
a i the work for which this Permit 4 issued (Sou. 3097, Or. C.)
W 0 Lenders Name
.a7. Z Lenders Address
U O I certify thn I haw read Nis application and ma tau the above infomudm is
ty ^. eorrem. i ague to comply with all city and county andinaneet ad sou Ian rt4dng to
O rV' Wilding conswetion. and hemby mNarim mpreanudves of this city teacher upon ase
til aWw-mmuosed Property for imp:euon purposes
gy (We) agree to sure, indemnify ad kap harmless the City of Cupertino agalns
scat h liabilities, jdlments, cam and ca enter which may In my ray smote against Said City
U 7 In consegmnca of the grmiing of this permit.
•^r
APPLICANT UNDERSTANDS AND WIL�yCOMPLY WITH ALL NON -POINT
sOWbRECULAT1911s. /r) _ _ - M /I ..
HAZARDOUS MATERIALS DISCLOSURE
VAR the applicant or future Wilding occuput sort or handle hauadou material
nd by tate Cupertino Municipal Cade. Chapter 9.13, and the Health ad Safety
Section 15332097
❑Yu ❑Na
Will the applicant or future Wilding occupant um equipment or dmim which
vsNaus air aanuminanu m defined by the Bay Ams Air Quality Mmagem l
❑Yes ONO
I haw road the huammss mm
ow a mums. that It 4 my responsibility to notify, the nupant of the
mus W mat dof w iamanm owccmfimu of fkmnancy. a
SUNDARI
Job Description
0053
nwtwrrns rsnmu trvro
REMODEL BATHROOMS W/SLIDING DOORS,
INSTALL RADIANT FL HEATING FOR FAMILY ROOM
M
Issued by:
Re -roofs
Type of Roof
Required Inspections
Date / G_/ 2--Od—
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better