04090235TY OF CUPERTINO
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DIVISION PERMIT
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BUILDING
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PERMITN`b4090235
20902 HANDFORD DR
WNER'S NAME:
PERMIT ISSUE DATE
HARISH S. AGASTYA
12/19/2004
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SANITARY NO. CONTROL NO.
ARCHr1ECf/ENGINEER: -
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I -by affirmNal I am icensed under provisions Of Chapter 9 (commencing
l.3of
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n]IXllp of Di'isiothe Businoas Nofessions Code.andmyliccvci+
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in orte and f"'
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Dale Contractor
ARCHITECTS DECLARATION
1 unMrsUnJ my plans shall he used as puhlio
Lkcnmd Professional or
OW NER BUILDER DECLARATION
I hereby affirm that I am exempt from We Contractors License Law for the
following mourn. (Section 7031.5, Business and Professiu s Code: Any city or county
which ".in. a Pemit us construct, elle, improve, dcmufish. or repair any +micros
810000
prior to its issuance, also requires We applicant for such Permit to Ole a signed sulemcm
Ft. Floor Area
that he is licensed pursuant to We provisions of We Contractors Ucens Law (Chapter 9
Sq.
Valuation
(cmem.neing with Section 7") of Division 3 nrum Business and Puressions Cole) or
that he Is exempt thes(rom and Webasis for the alleged exemption. Any violation of
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Occupancy Type
Section 7031.5 by any applicant for a Permit subjects We applicant o a civil penalty of
not more Nan five hundred dollen ($50%
I,ssowncr of the propcny, or my employer with wegv uNeir sok wmpenssuon,
Required Inspections
will do We work, and theatrumure is notintcndetl or offered forsalc (Sec. 7044, Business
and Profession: Coda: The Contractors License law door not apply 0 in owner or
property who builds orimproeslhemonandwho does+uch work himselfor through his
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Own employees. provided that such improvements are not imended oroRered for sale. if.
however,Ne building or improvement u sold within om Kar of completion. Ne owner-
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builder will have the burden of proving Nat he did not build or improve for purpose of
sale.).
❑ h as owner of We property, am exclusively contracting with licensed conmcton in
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construct the project (sec. 7044, Business and Profession Code:) The Conuactari U -
cave law docs not apply to an owner of property who Wilds or improves thereon, and.
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who contracts for such projects with a contractors) licensed pursuant o the Comacloes
License law. -
(3IamexemptunderSec. . B 6 P C for this rtvon
net Date
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WORKER•SCOMPENSATIONDECLARATION
1 hereby aRlm under penalty of perjury ow of Nr, following tlalantiov:
I have and will maintain aCenifei e of Consent to self -insure for Worker'sCompen-
cation, as provided for by Section 3700 of the labor Cock, for We performance of We
work for which this permit is issued.
n I have and will maintain Workers Compensation Insurance, as bol by Section
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3700of We LaborCodefor to perform of the wo if which this permit is issued.
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My Workers Campcvation Ivunnce ca Policy number-
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CERTIFICA OT�Pn0N FROM WO K
COMPENSATION INSURANCE
(Dais section need not hecompleted if the permit is(Damn, hundred dollars(SIM)
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I certify Nat in the performance of the work for which this permit is issued, 1 shall not
employ anypersm any manner an as to become subject to led WorkelY Compensation
Laws mf California! Dole
Applicant
NOTICE 7O APPLICANT: If, after making this CenNcate of Eirmanion. you should
become subject to the Worker's Compensation provisions of the "her Code. you mute
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faMwi to comply with such provisions or this permit shall he deemed revoked.
i CONSTRUCTION LENDING AGENCY
Iherby a?Int Net Vert isclending agency I'm We Performance of
' IWwurk for which Nu permit is issued (Sec. J09'l, Civ. C.)
Landers Name
Lenders Addsss
j I century Nal 1 have read this application and sum this the aWve information is
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' career. I Agree to comply with all city and county ordinances and stale laws relating to
building construction, and hereby authors represemuives of this city to enter upon the
above-mentioned property for Inspection purposes.
(We) agree to save, indemnify and keep ho mless the City of Cupertino against
i liabilidu,judgmcnts. cuts and a.,.'. which may in any way accrue against said City
in eonsequcnce of the Starting of This permit.
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' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE EGU71,yATIpN s. '
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by�ol..� LL 1 y3�
Re -roofs -
Type of Roof
Sag pylic HAZARDOUS MATERIALS DISCLOSURE
Will We applicant or furore building occupant stoic or handle haraNaus material
as defined by We Cupenimo Municipal Code. Chapter 9.11, -and We'Health and Safety
oJe, section 15531(:)?
All roofs shall be inspected prior to an roofing material beim Installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or dcvicea which
mil hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes XNu
I have mad Ibe hmardouemasdals rtquimmcnu underchapter 6.95 of the Califon
ria Health A Safcty Code, Sections 25505,75533 and25534. 1 micknrind Natifplc Wilding
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Jags nal curtenlly lame a aenan4 Na it u my msponsiM1ility m noulj the occupant of Ne
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requirements which must M mel prior to issuance ofa Ccnifiew, of Occupancy.
Slgnatu�llcant Date y
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All roof coverings to be Class' B" or better a'•
Owner pr auihofi.d crit am