05050139 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION "
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BUILDING ADDRESS: PERMIT N%5050139 5050139
440 F'ARAT T c)yE. LIR
:da'S NAME: PERMIT ISSUE DATE
�j SAILENDRANATH SAHA
HE SANITARY NO. CONTROL N0.
ARCHITECDENGINEER: BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
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X00 LICENSED CONTRACTOR'S DECLARATION
Z C 0flo
I Mrtby i form Uut I am Licensed under provisions of CMpter 9(commencing Job Description
<U with Section 9 )of Division Sof Om Boas.andi Professions Code.and my license is
^-ern infenmree and,Tres 1.1275 E> ADD 660 ' (FAMILY/BEDRM) & �� ����
p v�,(? Lieenu CI Lie a -
L�w Dam 'T Canttanar REMODEL
ARCHI'IELTS DECLARATION
¢ 1 understand` my plans shall W used as public records �9
=oG L,� mf�mnal Q JAN 2006
5 OWNER BUILDER DECLARATION
<I 1 hcrchy affirm thoi 1 am exempt from Ne Convenor's License Law fur the
0 o fallowing reason.(Soc mer 7031.5.Bminews and Professions Calm:Any City or countyv'g ` ',l ,'' wg4
K$ which mel a Permit to construct,alter,improve,demolish.or repair any structure i 'y;.>'La -47
x„ prior m its issuance,also requires the applicant for such Permit o Ole a signet statement — f�
Fie mat he is licensed pursuant Re,previsions of fc Contractor'sLineme,Law(Chapter 9 Sq. Ft. Floor Area I qq vs .0
yam (commencing with Satiun 7000 of Division 3 of the Business and Professions Conc)or -•--
'E'`s$ Nat b,u exempt Ocrefrom and the buns for the alleged Assumption.Any violation of
Section 7031.5 by arty applicant for a Permit subjects the applicant M a civil penalty of APN Number Occupancy Type
not mom Nan five hundred dollar(350(0).
Ql,uawneraf Ne proprny,amy employees with wagesuumv sole eompewsion, 36929012 ' 00
will do Ne work,and the structure is notimended or offered fonale(Sec.7064,Business Required Inspections
And Professions Code:The Conmactors License Law does not apply M e an owner of q P
property who builds or improves there..,and who docs ouch work himself tar through his
own employees,provided Nm such improvements are not immnded or offered for sale.If.
however.the building or improvement is sold within one yeu of completion,the owner-
builder will have the burden or proving Nat he did not build or improve for Im you of -
salal.
❑I,u owner of she propenY•am exclusively contracting with licensed convacmrs M
construct the project(Sec.7044,Business and Ptufesimns Code:)The Contractors U. `
cense law docs not apply M an owner of property who Wilds or Improves thereon,and - -
wh0 convacls for such Projects with a contractor(s)licensed pursuant M the Contractors
m e law,
om exempt undo Sec. .B&P C for this..on
Date
WORKERS COMPENSATION DECLARATION
_ 1 hereby of res under penalty of perjury,on of the following declarations:
Ihave and will maintain a Cerufiam of Consent M selbinsumfor Waukcr'aCompen-
satimn,az provided for by Section 3700 of on,labor Code,for the Performance of the
work for which On permit is issued.
❑1 have and will maintain Worker's Compensation Insurame.as soquined by Section
37W or the labor Code,for de performance of the work for which this permit is issued.
My Wormes Compemation Insunneepartier and Policy number am:
Cannot:
S:t+..3e- FIAnN Pnli,N..: )Y'.of-t3L'Ib-04
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE '
(Thu section need not he complcwd if the Permit is for one hundred dollars($10()
or Ices.)
1 certify that in she Performance of the work for which this Permit H issued,l shall not
employ any person in any manner so u to become subject to the Workeri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making his CeniOcam of Exemption,you should
WCOMC subject of the Worker's Compensation provisions of the labor Code,you most
oZ forthwith comply with such provisions or this permit shall W domed revalued.
z CONSTRUCTION LENDING AGENCY
[r I hereby affirm Nat Nem is a construction lending agency for the performanec of
y'
the walk for which this permit is issued(Sec.Ryer.Civ.C.)
all Q Lenders Name
a z L<nderi Address
U O 1 ccnify Nat 1 have read this applicant..and stat,that do above fi for.d..is '
f^ cormet 1 agree M comply with all city and county ordinances and also,laws mlaoing ae
0U building construction,and hereby authpme representzsives of this city to enter upon the
Y44[l a1Wvc mentioned property for inspection purposes.
,r gy (We)agree to save,indemnify and keep harmless the City of Cupertino againn
fq liabilities,judgments,costs and expenses which MAY in any My aceta,against said City
U inconsequence of the Starting of this Permit, r
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
sovacERlp I.ATIONs. '7(ly(Ur Re-roofs
Signature of ApphcanUazM
Comer l Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will th,applians or forum Wilding.Ccupam some or handle buardous material
Oned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
e.scenes ss3z(a)7 All roofs shall be inspected prior to an roofing material beim
❑ne. Na P P Y g g installed.
Will Ne applicant or future building occupant esu equipment or devices,which If a roof is installed without first obtaining an inspection,I agree to remove
it havardous air contaminants As defined by the Bay Arca Air Quality Management all new materials for inspection.
iatflc0
❑Yes
I have read Nc haurdnusmamrials requirements underchapser6.95 of Ne Califon
ria Half&Safetycade.5eedou MMS.25533 ud 25534.1 understood dela fore Wilding
does rout currently have a Tenant that it is on,mapmosibiloy M notify the occupant of the
myuir,N which mot befit prior Mifmance.f.aniRam.f a,uPaney. Signature of Applicant Date
o—wneror/�-samartmaesent �\ o ti(0 1l All roof coverings to be Class"Bi'or better
— r