04050019 CITY OF CUPERTINO •" aa
BUILDING DIVISION PERMIT fiCOM TRACTOR INFORMATION ,,
BUILDING ADDRESS: PERMIT Ncb 4'0 5 0 019
940 HOMESTEAD RD-_1NQQ
M'S NAME: PERMIT ISSUB DATE
DR. MIRA GODIWALA
ONE: SANITARY NO. CONTROL NO,
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOQ LICENSED CONTRACTOR'S DECLARATION
Z C I hereby affirm Nal 1 am licensed under provision of Chapter 9(commencing Job Deserip n
<(! with Scnion7(ggH of Division3of NC Ousinrssmd Professions Cnde,and mylicen.is
A /a
e� in mumrceandOffset. TI--DENTIAL OFFICE
HT
License Class n AUZS..
?0p4Udcon
ARCHITECTS DECLARATION
1 understand my plans shall he used.public records q00
;oG Licensed Professional /�M9VAe®ep„
g OWNER-BUILDER DECLARATION
I hereby affirm Nal 1 am exempt from the Contractor's License Law for the
p o following mason.(Beetion 7031.5.Business and Professions Code:Any city or county
m Pi which"uims a pooh to eh.14 alter,improve.demolish.nr mpair any slructme
Zm. prior to ita issuance.also"Uncs the applicant for such Permit to file a signed statement
F < that he is licensed purmanuothe pmvitiumsofOCConlnctohLicen.Law(Chapter 9 Sq.Ft. Floor Area Valuation
yam$ (commencing with Section 7000)of Division)of lbs Business and Professions Code)or
Je _
that he is exempt therefrom and the basis W the alleged exemption.Any violWon of
Semon 7071.5 by any applicant fo a permit mbjeets the applicant to a civil penalty of e10 0- Occupancy Type
not more than five hundred dollen
❑I,as owner ofthe property,army employes with wagnsaadmirmlccompendation,
will do Neadeas and the she Communities
Lamense&U,it fowl apply o a comer
m r of Required Inspections
and property
who
Cade:The Conuazmts Umme does does rot apply t.rt owner of q P
property who builds or improves thereon,and who does such work him.lf edthough his
own employ..however.
00building
provided Nat such impmwmenu ere not Intended ioimcm.for safe owner.
builder,Nebui1 the orimprovementisold within oneyear ar mmpletionr the use of
builder will have the burden of proving dist he did test build w improv for Dulpo.of
sale..
1.as owner of the rmpe ty,am exclusively commanding with licensed contractors to
met the project(Sec.1044.Bummoo and Professions Code:)The Contractor's Li-
tome law dos not apply to an owner of property who builds or imposes thereon,an4.
who contacts for such pmjccu with a cantrm umm licensed pursuant to Ne Canmaclo`3
License Law.
I exempt am ,B&P C for this reason
Date 0
RKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the follssaiaadeclantim s:
I lose and will maintain a Certificate.&Consent an self-irsomme four WorkefsComPen-
motion,a provided for by Section 3100 of Ne Labor Cade,for the performance.f the
work for which this permit is issued.
71 1 have and will maintain Workes Compensation Insurance,as mquimd by Section
3700 or On labor Code.for On pe parmmec of the work for which this permit is issued.
My Worked Compensation Insurance comer and Policy number art:
Carrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Ttnia section nem not heeompleted if the permit Is(o one hundred dollars($]W)
or less.)
I certify Not in On performance of the work for which this Permit is issued.I shall nod
employ any person in any mannerso its,ta become subject to Women''Csmpcwtion
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making Nu Cenilmadc of Exemption,you thouW
Woman subject to the Wahch Compensation provisions of Ne Labor Code.you mast
�Z foMwi h comply with such provisions or this permitahall be deemed ewoked.
Z O CONSTRUCTION LENDING AGENCY
(-. V) Ihereby ares Nal tem is a construction lending agency fat the Performance of
C> the work fur which Nis permit is issued(Sec 3091,Civ.C.)
QLendcYs Name
Leaderi Add.,
V► 1 certify Nat 1 haw mad this application and state Nn to.bow infamadun u
t'^ correct I agree to comply with all city and county ordinances and state laws relating w
O V building construction,and hereby malmom rcpmacntatiws or this city in enter upon On
C7) aho.cmcmtion,d pmpeny for inspection pulp...
f1 (We)egme Io sass.indemnify and keep harmless the City of Cupertino against
fA liabilities,judgments.coo and expenses which may in any way Acca,agaivB said City
C)z APPLICANTeof the UNDERSTANDS AND this
WILLWILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE REGUympNS.
�i `-fYf►l�1/Y Re-roofs
Si mum of ApplicanJCanm.mf ate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or futile building accupmt mom or handle haaallous material
Oned i' the Cupertino Municipal Code.Chapter 9. Z sad to Health and Safety
e.I0yenz553z(ar ,{//,,' All roofs shall be inspected prior to any roofing material being installed.
�Yns IN.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or mare building mcupam use egaipmmt or devices which
7dL',-
harardnus air conuminanu fined by the Bay Area Air Quality Minagcmcm all new materials for inspection.
rict?
Yes
I have mail Ne hvanlousma¢rials equimmenta under Chapwr6.95uf Ne Cxiifor.
HcaIN&Safety Code,Sections 23NI5,15533 and25534.1 undcrmand thalif the Wilding
not currently have a tenant Nat id is my responsibility o madly the eccuPau Of the
irements r�eh .met rioraimamd,oft ceniRcale dicapmey. -gy Signature of Applicant Date
r(d' � 1 All roof coverings to be Class"B"or better
r authorized agent I Dam