06030140 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,Q,QNTRACTQR INFORMATION
BUILDING ADDRESS: PERMITN0.
0150310140
858 E ESTATES DR
'.R'S NAME: PERMIT ISSUE DATE
PALLIPURAM 695 S . 15TH ST. 03/24/2006
PHONE: (408) 298-2374 SANITARY NO. CONTROL NO.
ARCH17ECUENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�oo LICENSED CONTRACTOR'S DECLARATION lob Description
1 hereby affirm that 1 ad licensed under previsions of Chapter 9(commencing
vim Section 7").f Division 3 of In Business and Profesainu Code,and my license is
mmumreeandef¢n. �3 y REPAIR 10 LINEAR FT OF SIDEWALL PERIMETER
u.mnm�comgxmrG�7 FOUNDATION
d HIIELTS DECLARATION �'NALE
1 uMenund my plans shall he used u public ranrds
°ycgLicensed Profcumul
C3 OWNER-exempER DECLARATION
O y I hereby.Riad Na 1 I. exempt train he fumm ars License law for IM MAK S t- 2005
COO followinguirasa (Saito 7omm Business and Ponimprove.
demolish,
My city or county
$ which requires•permit o.aura,alar,impress,de emit i or repair any structure _
_Z;m tprior hat M i u issuance,c,o also requires the
ovisio IALs of for such pctor're Ma an,Law comment
< ,hal mencinnsedpursuant7000)ofDivisionfdmheBuausAndPrsclAw(C Code)or Sq.F[. Floor Area aluati
980
that he
nvarint And of basis for
of the Bminmeandon.Any vi Cndc)of
.. mat he b ea.b therefrom and the bob for the alleged exemption.Any l Penton of �I
Sectio 7031,5 by any applicant for permit subjects In applicant to a civil penalty of Ty7�y�g� p y • pe
BI III
ml more dun fin huMrtd dollars(f300). 36y2,'aj•p=�� QQ CU araC �l
❑I.ac owner of me property.Air my emplayce,with wages ere their sole(Ximpensatlon.
will do the work. itlieswnun b not intended nr offered fmmam Ism 7W.BusircuRe aired Inspections
and Prefnuion Code:The Contractor'.License Law docs ml apply o an owner of q P
property who builds err improve,thereon.and who dues such work himself or denugh his
own employees,provided mtsuch improvonscrea ,not Intended araRered far ole If,
however,the building or Improvement is said within am Seo of completion.the owner.
builder will have de burden of Moving flat he did ret build or improve fm purpose of
tale.).
❑I.As owner of the property,am"elusively contracting with licenad contractors;to
construct the project(Sec.7064,Business and Prof"slon,Code:)The Chamber'U.
came law dace not apply in an owner of prepeny who Wilds or Improv therman,and,
who concocts far such projects with a cumsnum(.)licensed putamnl to the Conuactoes
License law.
❑lamexemptumemsea ,BAPCfmthbreaon
Date
WORKERS COMPENSATION DECLARATION
I hereby aBirm under Nulty of perjury am of the following decleradom:
❑[ham and will maintain acenlOca inf L'oment to self-LuenfnrWorhaYsCaopen-
Asian.As provided for by Section 3700 of the Labor Cade.for the performeme of the
work for which this permit is ismd.
❑1 bare and will maintain Winters Campemadan Insurance,as required by Section
3700 of the Labor Cade.For the performance of the work for which mis permit la iamd.
My Workers Cadperadon Insurance artier and Policy number am:
Cartier: Policy No.:
CERTIFlCATE OF E%EMPnON FROM WORKERS'
COMPENSATION INSURANCE
(Thna mire reed nothacompleted ifthe permit Is foram hundred dollen(5100)
at me.)
I certify that In me performance of the work for which Its permit Is issued.I shall net
LA.iaany person �o mvlubjana the Warkeri Computation
Lowe of Calif LLNN is '
Applinnd
NOTICE LI ANT:If�l�im�ng thu Certificate of FampuN
con,you uuld
become au o the Workers Compensation povisiom of the Tabor Cade,you mol
.J O forthwith Comply with each provision or mis Noe tshall W deemed revoked,
Zy CONSTRUCTION LENDING AGENCY
EIherehy.fRrm thattheo bamnuuctinn lcniingagemy,for me pnfurmameal'
> de work for which thin permit bme
named(Ser.3M.Civ.C.)
ME Lender.Name ,
Z Lernmes Addmua
U Q I eenify dol I bas rod this application and state that the above information Is
(L F torten.l egret to comply with all city and county ordinances and eau laws cluing to
CV building construction,and hereby authorize mpresena,has of this city to enter upon the
U ahavc-mentioned pmpcny for impaction MrpuCL
gy (We)ague to an.indemnify and keep homeless the City of OnNnino against
a.tcn Ilabiliticajudgmenta,ensu and expenses which may in any way accrue against a id City
(,•) in consequence of the Starting of this permit.
APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 3- ZYcss
SO RC R• LATION
Re-roofs
SI uumo pp8ean esu or tee
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Wild the applicant or future Wilding accupantstore or handle hazardous maunal
defined by me Cupertino Municipal ,Chapter 9.12.and the Hcalth and Safety
.Section 25532()? All roofs shall be inspected prior to any roofing material being installed.
❑Yue u
Will In applicant or future building oauuanl um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
earl,hazardnm It contaminants As dcfi by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes o
I hive mud Oc huardns maenads equimmenu under Chapur6.95 of the Califor-
.I.Health&Safety Cade,Sectors 25515,25533 and 25534.1 understand then ifthe Wilding
Jam ret in nand,hen a uaanc that It is my rmpomibility omdl'y the aaupanl of the
oquircwnm% 'hmpdor iuu ofead metflcirTyfdJ tpmner. Signature of Applicant Date
Low.,au,harieed age in All roof coverings to be Class "B"Or better