05120021 CITY OF CUPERTINO * tux« P,q�,>�x M o m'rsz9"-= '3,.
BUILDING DrnsmN PERNIIT ��01YTRA TOR INFa'RMATII'ON "
NFORaa .,AT d
BUILDING ADDRESS: PERMIT ND.0 5,12 0 0 21
1143 HOLLYHEAD LN
OWNER'S NAME: PERMIT ISSUE DATE
RAGHAVAN EMBAR 02/17/2006
E: SANITARY N0, CONTROL NO.
ARCHI7ECI7ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLO MECH
O
300 LICENSED CONTRACTOR'S DECLARATION lob Description
g1 hereby afOrm that I w licensed under prevision of Chapter 9(commencing p
with Stttian 7")of Divixlon 3 of the Business and Prefcaaioru Code,and my license is
n'1 in fall faro and effect. REMOVE INTERIOR WALLS/INSTALL CEILING BEAMS
j z License Class Lk.a
Dale Can,.,
ARCHITECTS DECLARATION
I undcraund my plan¢hell be used as public rtcnrda
g a.G S Licensed Professional
OatNEm exempt
DECLARATION
COO 1 nanny.(Brun that 11. exempt from the Comment's Cox License maw for the
COO 9 followwhich
uiron.lemic t 7031.5.B.aliv. end w,demob Code:Any city or county
5$ which it issuance,
¢permit toconstants.Blue Improve,demlllitt ore pairanytaroctum $33852
_Z pdormitscense pursuant I.
theres the powiseapplicant forsuch C.,dossmiva NcasLaw(Chapter
fina,Its mormar licensedpSectionretheofDiaionsafthe eBuinessamJcenselaw(Chepmr9 Sq.Ft.Floor Area Valuation
(commas xemwith Section 70010 ofs basis or Of for al eged exem t on.Any vi Code)or
dol he ts exempt Cem(rem and Use bun for the Waged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty a( 3 APR Eg,r��
Out more Nan five hundred doll.H500). r os ancy Type
❑I,uownaofdiepmpmty,wmycmploycawith Mguuthekmkcompewdon,
will do the work,and the structure lsnotkmneed or offered formle(Sec.70 .Businu Required Inspections
and Prefeulon Code:The Cmuacmrs License Law docs not apply to an ownnser of q p
property who builds sur improvex themon,end who chess such work himalf or Through his
awn employees,provided that such improwmenu are notim anded aroRemd for sale.If.
however.Ne building or improwmant Is said within one yaw of completim.Cm names.
builder will Mw the human of pmrfng that he did not build or Improve for purpose of
Alc.).
❑1,As owner of the property,am exclusively contracting with licensed conuacims in
consumer due project(Sec.7044,Business and Profexdons Cade:)The Cantracrers Li.
cease taw coca not apply b an with
a of property who buil pursuant or unpiovu Corton.and 1-41
whence La ufor Ash projects withernnlnda(q licenseere Nt ConvenoM1
License
Law.
❑1 em exempt under Sec .B @ P C fa This reason
61 ! 06
wnerS . S .,/D/\A1L� Dam
WORKER'SC tyo(pc uryamoEC folia Ing
1 hereby alum unser perW ly of perjury arc of the(allowing cttlentian:
❑than and will maintain&CemOcemuf Canemmalf-Pnsomfw Worker's Compere
Adan,u provided for by Section 3700 of the tabor Code,for the performance of tae
work for which this permit is Issued.
❑1 neve And will maintain Wotktrs Compensation Insumuce,A mquired by Section
37M of the Isbor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Inmanm carrier and Polity number art:
Carrier:. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This rection need notbecmnplemd If the permit Is foraue hundred dollen($1110)
I anify that in the performance of Ile work for which this Permit is issued,I Aall not
employ any person In any munn�Yu�y WcoayeAuglecl m de Workmi Compensation
tanto(Cahf9mnLDL yT.T F ((�a
Applicant TO
NOTICE TO APPLICANT:ei afterCom making thioCertificateprovisions
sof of Exemption,you should
.JOftthwihcompome subject m it WoherSComp Or this pmviaiau of the LAW Cock,. mug
forthwith comply with such provisions Or this pcmitshdl be decmW revoked.
Z CONSTRUCTION LENDING AGENCY
vN.,i•' Ihemb am.that Clete u a coomuctinn kndin ac Y { .)my fm me perfurmenceof
lYi ti the work for which this permit Is issued(Sec.3097,Co,C.)
aQ lender's Nems
D Z Lenders Address
U 0 1 certify that 1 haw mad this Application and sum that Ne show information is
I, correct I agree to comply with all city and county ordinances and sum laws mining in
p building construction,and hereby amhorime mpruemstias ofthis city to curer upon the
W above-mentioned property,for Inspection purposes.
LL (We)Agree to Ave,indemnify and kap huri the City of Cupcnim again,
rA liabilities,judgments,toss,And expenses which may in Any My acme sgainal said City
f�z in consequence of the grmling of this pemtL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
7SOU CEREGU ONS.
S: - y�17 Re-roofs
Signature of AppliMUConuAclor Dat
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant atom or handle haamous mamrlal
As dented by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code,Section 25532(a)?
❑Yes ❑Nu All roofs shall be inspected prior to any roofing material being installed.
Will the Applicant or future building=upon,use equipment or deviaa which If a roof is installed without first obtaining an inspection,I agree to remove
lDiwirt?
hasardon air contaminants u defined by the Bay Area Air Quality Management all new materials for Inspection.
❑Yes ❑No
1 have read the harsmous ma trials requimmenu under Chapter 6.95 of the Califnealth d:SafctyCodc,Sections 255(15,25533 and 25534.1 undcraund dor ifthe holding
not cumntly hew a mount,thus It k my ampoesibility m ratify the aaupunu of the
menu which 9kmet prionaisauaceofa Ccrufcemp
of Father Signature� Signature of Applicant Date
Owner or authorized agent All roof coverings to be Class"B"or better