04060113 CITY OF CUPERTINO
BUILDING DIVISION PERMIT " CONTRAC-°TOR INFORMATION
BUILD
ING ADDRESS: MARVIN DAVIS CONSTRUCTION PERMITN004060II3
'R'S NAME: PERMITLSSUEDATE
UMESH HIRIY
ONTR
JNE:
SANITARY NO. COL NO.
(408) 975-0200
ARCHITECTENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uoo LICENSED CONTRACTOR'S DECLARATION - --- - - -- - - --- - ---- --- -
YU� lbembyaffirm mal lam Become ander prnviarons arcWptervuammAnemg lob Description
n� wOm tion7")of Division3orft Businmuld Professions Codd.andmylia=is
j�, mmnmre andeffect, t'15r/ � II-5�2� ADDITION-2 BEDROOMS (57 SQ FT)
Lieen �Lln L
;moo Dam -Z�' ca trmmrp AU_1 •I'D/j1c GARAGE (240 ' ) KITCHEN RE gLe
ARCHITECTS DE�{,pji ION �'•/�
5y¢< I '7rs plata shill W tied u pub is or
oats w
3 o G Licensed Pmmssion
S NEM BUILDER DECLARATION I
1 hcrehy affirm that 1 am cumpl from the Contractor's License Law for the UN
p o following reason.(Section 7(A 1.5,Business and ProfeasiOM Cade:Any city m county 'r
vim which reyuiroe A Pemtit to Co.,. H.M.aimprove,demolish.m repair any AA.UUA
_zi prior In its issuance.also requires the applicant For such PermiOo file a signed sutemanl
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For he is licensed pursuanttothe previsions ofthe ContwouriLicense Law hapmr9 Sq.Ft. Floor Area Vah3$tc81560
9�G (com mencing with Section 7")of Division 3Of the Business and Professions Coes)or j
A. that he uerthe eanpi therefrom and basis for the alleged exemption.Any violation of d3 v
Section 7031.5 by any applicant for a permit subjccu the applicant to a civil penalty of � - ti
not mom man five hundred dollars(s500). APNNumber d;y y40c ancyType
C3 1.as owner of the property,or my employees with wages Air their sole compensation, 37529007 ' 00
will do We work.and me slmcu e isnot intended M.Mined for sok(Sec.7044,Buvnw
and Professions Cnee:The centimes License law dem Mt ply m an awtter of Required Inspections
progeny who buildsarim news thereon,and whodoessuch work himselfor through his
own employees,provided mal such improvements are not intended oroQemd for sale.If.
however.the building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑I,as owner of the pmpeny,am eaclusively contracting with licensed contractors to
conswct the project(Sec.7044,Business and Professions Code:)The Connector's Li-
cense law dues not apply to an owner of progeny who Wilds or improves demon.and
who contracts for such projects with a contractor(s)limited pursuant to the Contracroes
License Taw
Alec],
pt under Sec. .B&P C for this mazon
Date
WORKERS COMPENSATION DECLARATION
I affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Campeau,of Conscnl to self-insure for Workcr9Compen-
.I'm,as provided for by Section 37M of me labor Code,for the performance of the
work for which this Permit is issued.
❑1 bac and will maintain Worker's Compensation Insuran c,as,mquired by Section
37W of the labor Cade,for the performance of on,work for which this permit is issued.
My Worker's Compensation Insurance Cartier and Policy number am:
T;.)"n Idood: 11(nOR(P-7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE H-0S --
(Thes section need not W completed if the permit is for one hundred dollars(SIM)
or less.)
1 ccrufy mal in in.perfamunCA or me work for which mit permit or issued.I shall oat
employ any fiction in any manner m As m become subject to du,Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subjmt m the WOrkv'3 Campensstion provisions of Be Libm Code,you muse
Z forthwith Comply with such previsions or this Permit mail W deemed revoked.
'POCONSTRUCON LENDING AGENCY
't-s TII hereby alfpm that mere is a construction lending agency for the Performance of
Cone work for which this permit is issued(SAC.3(197.Ci,C.)
W IandI N.
M
Z Lcnllcr's Address
U Q 1 Certify that 1 have read this application and state that the above information is
come,.1 agree to comply with all city and county ordinances and sum laws relating to
0U Wilding construction,and hereby aumonm rtpremntatives of this city to enter upon the
W
abovcmentioned property for inspection purposes.
(We)agree to save,indemnity and keep humless Be City of CuPcMW against
F" liabilities,judgments,costs and expenses which may in any way see=against said City
U in consequence of the granting of this Permit.
^ APPL PIT UNDER ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
,/W27��
SOU C RE^ULATI S.
�'O.014 Re-roofs
Signature of ApplianUC rr cmr Dale
HA AgDOUS MATERIALS DISCLOS RE Type of Roof
Will tW applicants um Wilding Occupant store or handle hvatdous manna]
Fined by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safny
Section 25532(a)7All roofs shall be inspected prior to any roofing material /eing installed.
❑yen flu
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hanomus air contaminants As defined by me Bay Area Air Quality Management all new materials for inspection.
Dialric0
O Ycs �u
1 have mail one haia dommaterials requirements under Chapier 6.95 Affix Califon
nia Healm&Safcty Code,Sections 255(15,2553]and 25534.1 undersand mardthe building
does ntenant,
ot c recopy hove that it is my responsibility m a
nouly the cupenl of the
Otpore wit It Am met poor toi'siofaCCrdfiesteofOccupancy. Signature of Applicant Date
Owner or autho mind agcn Date All roof coverings to be Class "B"or better