05080148 CITY OF CUMIXINO mc« ,��
BUILDING DIVISION PERMIT r CONTRACTOR INFORMATION a:�.
BUILDING ADDRESS: M & M CONSTRUCTION PERMITNO.05 08014 8
1044
ER'S NAME: PERMIT ISSUE DATE
SAILENDRANATH SARA 36318 FROBISHER 22 2005
'ONE: SANITARY NO, CONTROL NO.
(510) 673-0077
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
trop LICENSED CONTRACTOR'S DECLARATION. Job Description
C I hereby affirm shat I am licensed under provisions of Chapter 9(commencing
In with Section 7000)of Division 3 of the Business and Profession Code,and my license is
^cy imm�romeanacrr«I. 27-5-5
REVISION--BAY WINDOW/REMOVAL BEAM (4 X4)
p�? License CW, Lic.0
r�o
Dow N1z71� Coatoner, NO NEW PERMIT ISSUED/ORIG. #050500139
np ty T ARCHITECT'S DECLARAT N
dy C-t I understand my plans shall W used as p ldie moords
>yU
g G Licensed Professional
OWNER-BUILDER DECLARATION
I 1 herehy affirm Nal I am exempt roam the Contractors License Law for the
OO following mason.(Section 71131.5,Business and Professions Code:Any city or county
C
m which=quirts a permit to construct,eller,improve,demolish,or repair any short..
y2t print to ox issuance.also re,om Oc applicant for such permit to rale a Signed statement
< thatWisliresxdrampanuotheprovisionsoftheCommon'sLicenseLaw(Chapter9 Sq. Ft. Floor Area Valuation 0
ga (commencing with Section 7000)of Divism.3 of the Business and Profusion Ccdc)ser
_ that he u exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applica d 10 a Civil prnahy of APN Number Occupancy Type
not ten.than Rve hundred dollars($500). 36929012 . 00
❑Luowner of U.propcny,amy employcu with wages tithe"v sole rompewtion,
will do the workend Ne powasm is not intended or offered r...ic(Sec.7Oaa,Business
and Profession Code:The Convectors Littre taw does not apply to an owner of Required Inspections
property who buil&orimVoves thereon,and who doeasuch work himself or Borough his
Own employ=.providcd that such improvements are not intended oroffemd forsak.It.
however,Ne building or improvement is sold within one year of complotion,W,owner-
builder will have the humen of proving that be did not build or improve for purpose of
sale.).
❑1.as owner of the property.am exclusively contracting with licensed contractors i `\
wornLa des not (Sec.o aa.Business and property
who
Cade:)The ma Orr on. n
who c law docs not apply je an owner of popery who Wilds.improves Comeas and
who contracts for sato prole.with a conuactor(s)licencd Petermann to tk Conuxsors -`
License Law. fV\
❑lam exempt under Sec. ,Bk PCf.r thismuon
137Wer Data
WORKER'S COMPENSATION DECLARATION
I hereby aRnn under penalty of perjury one of the following declaration:
nave and will maintain a Certificate of Consent m sa lf-irm.for Workers Cometen,as providcd for by Section 3700 of U=tater Code.far the pcottrman.of Ue
for which this permit is issued.
have and will maintain Workers Compensation Insurance.n mqi.d by Stction
ofthe labor Code,for the performance of the work for which this penisis issued.
Worker's ComproemdomInsurance carrier and Policy numberart:so. SJa k RNI't61' policy No.: tykg-paj-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
QTis section need not W cusnplemtl if the permit is for one hundred dollars($100)
less.)
1 certify that in Ne performance.f the work for which this permit u issued.I shall not
employ any person in any moaner so as to become Wbjca to the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions or the labor Code,you muss
.J Z formwith comply with such provisions or this permit shall W dermcd revoker.
'FO CONSTRUCTION LENDING AGENCY
[-�� I hereby affirm Nat then is a contrucLum loading agency for lW performanceof
CL the work fur which this permit H issued(Sec.3097,Civ.C.)
{g3 Q Lender's Name
=Z Lender's Addm_ss
U Q 1 certify Nu I have rual this application and sum that the above information is
Iy P correct.I agree.comply with all city and county ordinances and state laws relating to
O U Wilding conuueion.and hereby authoma representatives ofthis city to enter upon Ue
r ateve-mentioned pmpeny for inspection purposes
(, 0. (W.)agree to save,indemnify and keep harmless the City of Cupcnino against
N lomilitics.judgments,comm and expenes which may in any way acme against said City
U inconsequence of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REGULATIONS.
g V211o'- Re-roofs
Ssgnamre of Apphcan,Comnacmr I Dore
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Bot applicant or future Wilding occupant a==or handle haommus material
Oefined by the Cupertino Municipal Coale.Chap=r 9.11,and the Health and Safety
.Scmnnz5531(aT1 All roofs shall be inspected prior to an roofing material beim Installed.
❑Tea ❑NO P P Y g g
J` wise -:P pucam or future building Occupant use equipment ter devices whim If a roof is installed without first obtaining an inspection,I agree to remove
it hmardnes ir'onmminants u defined by Bot Bay Area Air Quality Management all new materials for inspection.
Disuict7
byes ON.
Ihavemm Neh na t)usmawrials.quimmcnuunder Chapter6.95ofNeCallfor-
nixHcalNkSafcsyCodc.Scetian13505.25533ud2553a.lunderswdthuifthc Wilding
does not currently has a moan Naz it u my nesponibility.notify IW bccuwt of the
moustswnfcnmu ismanmofaCrnirae0 crop. Signature of Applicant Date
Owneser authorizctl agent Z Daomw All roof coverings to be Class"B"or better
r cm '