04060001TY OF CUPERTINOlava>�§,'r**
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BUILDING DIVISION ppRMIT
# CONTI2AGT.OR IN„F.OR AjjoN:
NG ADDRESS:
01 JAMES TOWN DIR
E""','LDI
SUITABLE CONSTRUCTION
FERMITNOO 4' 060001
R'$ NAME:
PERMIT ISSUE DATE
BRAT JAYARAM
SANITARY N0. CONTROL NO.
(408)370-7120
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION'
Job Description
1 henry &from Nat 1 am licensed under provisions of Chapter 9 (commencing
with Section 70M) or Division 3 of the Businw and Professions Code, and my license is
in full force and effect.
REVISION—DETAIL BEAMS C
LicenseClus
Dam Contractor
(ORIG PERMIT 03070133)
ARCHDECTS DECLARATION
TSD
IN HOUSE NO NEW PERMIT
\
I understand my plans shall Wused as public rnenms
Licensed Professional
OWNER -BUILDER DECLARATION
from law for nm
1 hemhy .(Sero I em uusin rum tPr Commmo
following reason. (Section ]1131.5, Business and o e: Any C
on
mi Code: Any city or county
which ¢quireso sm fire
reprove.uh ignedswnum
pccotui
Kmdib,
a signed
also nt the applicant such pastor' m ole a signed smmmem
prior to its .also
the the
License law 9
Sq. F[. Floor Area
Valuation
isi ns of (Chapter
thnWisliccnsed Pursuamm NCPmvialonof Nc Contractor's
licensed p to
(commencing with Section 7000) of Division 3 of Ne Business and professions Code) or
0
Nat W 4 exempt Rmrefmm and the hss4 for Ne alleged exemption. Any violation of
APN Number
Occupancy Type
Session 7031.5 by any applicam for a permit subjeea Nc applicanuo a civil penalty of
net mom than five hundred dollars (551)p.
1, u owner of the pmNny, m my employees with wagu u dmir sole comNnmdon,
Required Inspections
9 P
will W dm work. and Ne swcmre is no, intended orolfO.d I ... Ie(ScOlIGUd,Bushmas
and Profession Code: The Conuactiri Licetwn Law docs not apply m an owner of
property who builds or impm lis Up,.... end who does such work himself of through his
own employers. provided but such improvements am not intended o0 o@rod for sake. If.
however. the building or improvement is sold within one year of completion, the owtmr-
builder will bane this burden of proving that he did nm Wild or improve for purpose of
ask.).
1, as owner of the progeny, am udusively contracting with licensed amo errs m
Construct the project (Sec. 7W, Business and Professions Code:) The Comractir's U.
cense law dors not apply to an owner of prepeny who Wilds or improves thamon, and.
who commcu far such pmjeeu with a eommeor(s) licensed pursuant on dm Conbamor'a
License law.
Iamuemplundersee ,B&PCfm Nisreamn
Dam
WORKERS COMPENSATION DECLARATION
I hereby strum under penally of perjury rex of the following dmleration:
1 hart and will mountain &Certificate ofComenuo self-usum for Worker'sCompcn-
.on , u Provided for by Session 3700 of the labor Com. for Ne pufmmance of dm
work for which this permit is issued.
❑ 1 have and will munuin Worker's Compensation Insurance. as required by Section
3700 of Ne Labor Code, for Ne performance of Use work for which this Permit is issued.
My Worker's Compewnon hmumnce carrier and Policy numW r M:
Carver. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W cmnplemd Hthe Permit is for one hundred unit= (SIM)
or los.)
I certify Out in the porfmmence of Ne work for which this Permit is issued, l ahJl our
employ any person in any mother art in in Wsomc subject to the Wofkeri Compensation
Laws of Califamia. Dam
Applicant
NOTICE TO APPLICANT: If, after making this; Cenifscate of Exemption, you should
become suhjut m the Worker's Compensation provisions of Ne labor Code, you must
[ forthwith such or N4 shall he deemed ¢,mired.
comply with provisions permiL
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is lending agency for Um Pcrfurmance of
s ed (Sec. 30
dr.Le work fur whiCM1 Nis permit is iuuctl (Sec. J09], Civ. C.)
Lender's Nene
� I,cndcr's Address
1 modify that I haus mad this application and sum Nat the about infmmNon 4
correcL 1 agree to amply with all city and county ordinances and nom laws relating to
building construction, and hereby amhmri a mpi,amm n,, of this city to enter upon the
n shove -mentioned Property for inspection purposes.
L (We) agree to save, indemnify and trip hnmless Use City of Cupertino against
0 limilitica, judgments. costs and expmues which may in any way acenum against said City
> in consequence of the granting of this Permit.
w APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOU RCE REGULATIONS.
Re -roofs
Type Roof
Signature of ApplicantiCminister Dem
HAZARDOUS MATERIALS DISCLOSURE
of
Will the applicant or future building Occupant Sloe or handle hunmdous material
as derned by Ne Cupertino Municipal Cod=. Chapter 9.12. and the Health and Safety
ode.seruon25532(a)+
All roofs shall be inspected prior to any roofing material being installed.
Oyes ON.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment fur devices whim
cm it hazardous air conuminanu in defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes ONO
1 have read Ne hvardous materials requirements under Chapmr 6.95 of the Califon
nice Hcallh& Safety Code, Sections 75505,25533 and 25534.1 understand that if tW Wilding
docs Out currently bane a tenant. that it is my responsibility on notify Na acupant of the
requirements which most W met On, In issamwe ofa[militate or Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner oraathorixedas=fit Date