05110110CITY OF CUPERTINO
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CtIIK=TRA.G'�nRNF4 RMATI
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO. 05110110
10335 JUDY AVE
0 NER'SNAME:
PERMIT ISSUE DATE
RAJASHEKAR RACHAKONDA
SANITARY NO. CONTROL NO.
ARCHrrECTIENOINEER:
BUILDING PERMIT INFO
BLDG PLUOMB MOECH
0
LICENSED CONTRACTOR'S DECLARATION
Job Description
p -
under provisioof Chapter 9 (comemkt
1 hereby afpres mat I m Ikcud ns m
with Section 701M0 of Dlv4ion 3 ofdte Burn and Profession Codo,and my license is
in full fore pld. cam
ADD BATH & CLOSET IN (E) MS BEDRM
License Class Le.0
Da¢ Caauuw
sS DEMc ATION
ARCHITECTS
mill meet&
1 undermnJ my plans still be used u public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby j Biirm that I am excmpl from me Conuunora License Law for the
fallowing (Section 703 1.5. Burns and Professinm Cade: Any city or =only
mason.
which mquirm a Permit to construct. atter, hnprove, demolish. m Mercer any sunpure
prior m its immune, sou mquiru tic applicant forsuch permit m flied a signed paknmnts
Sq. Ft. Floor Area
Vluatidit
wtne4licc=dpm LusWeprovisions ofineConvecmr,LicenmLaw (Chapter 9
(commmuint with Section 7000) ofth Brion 3oftic Businmand Profevions Cade)ar
A
that he 4 mempt Nemfmm and me basis for the alleged exemption. Any violation of
!
U anCy� pC
$ecdon 7031.5 by arty, applicant fee a permit anbjem the applbnl to a civil penalty of
not more than this hundred dollar ($SM.
�4
I.uowner of lRe gaperty, ar my employees with vatesuWa4 auk eampensdan,
a+
Required Inspections
Ve
will do the work. and thasuunum is notlmndcd erafferd formk(Sec. 7041,11us(nus
and ROfeWON Cade: The ConUYYar, License Law Law daWE apply m an Manor of
-1
property who build, or improvns caermn, and who das,ueh went himself m through his
owes employees, prrMded dmIm,h Improseman4 are, WE lamed aro@res for WE, If,
however, the building or Improvement U mid wid6nae year ofampkdm. th osvmr-
bulider will haw Wm burden of proving that he did ret build or improve for purpose of
ask.).
VII, an mwrc of the pmpeny am exclusively contruting with Rebound ren relic m to
Cam ort We pmjm (See. 7044. Business mid Prostitution, Cade:) The Cmuumrt U -
came LAW dam not apply m an owner of pmpeny-w1W builds or imprewf Woman, and,
who centuries for such pmjam wire aconuator(O licensed pursmm m WeCanlranwrs
License Law.
❑IameumPt un B & P C for 4 n
sea
Dam
I�WORKERS COMPENSATION DECLARATION
1 hammy arm under penally of perjury am of the folkwing declaruimts
❑ I haw and will maintain aCertiOamaf Comemm self-4mre fm WoheraCamper-
Wim. as prervlded for by Section 3700 of the Labor Col for the performvice of the
work for which cams permit is Issued.
❑ 1 haw and will maintain Workers Compensation incurrence. u required by Section
3700afmo Lemecodefmcaepurfomance ofthewrkfew whlchthispareeks 1mued
'
My Workers Compensation bwrence arum aro Policy number me:
Carrier: Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This auction need not incomplete If doe permit 4 forane hundred do0ara (SIM)
or kat)
I unify that In the performances of the work for which this permit 4 Wood, l shell not
empkyanypermninanymann rte m bameosubjeet an rite W Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If. after makint this Omillicau, of Famption, yeas should
become subject an the Worker's Compensation provisions of the, Labor Cee you mus
.
forthwith comply with tech pmvidam m this Permit shall be dmned moked.
CONSTRUCTION.1.aned"ING AGENCY
Tfm me perfomunte of
1herbyichnn mumem 4, enmm.i30kndiv.
C.)
' the work for which tido remit 4 iasud (5co. 3097. Civ. C.1
'
Lenders Name
Lenders Address
j I ratify that 1 haw mad this appliesdm and mte that the be. Information I.
comet. I agree m comply with all city and county ordinances and auk laws minting m
building consmmlion. eco hereby mthodm o presemedes of this city to emu upon rite
I above-mentioned property for Inspection purpases
(We) agree to eve, indemnify and trop harmless me City of Cupertino .&ME
I liabillWe;judgmCnu,Gap, and "pen which mayk anywaymcnac aga(ml,aid Coy
• In cmlaegnece of the granWnt of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE Uu Ns.
Re -roofs
a v /
/1/2/4
Signature of ApplianVConumar Dam
Roof
HAZARDOUS MATERIALS DISCLOSURE
Type of
Will ma applicant or future building accupert rare or handle hasadou m,krial
an, deRncd by the Cupertino Municipal Code. Chapter 9.13. aro We Health and Safety
Secure 21532.)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes W140
If a roof is installed without first obtaining an inspection, I agree to remove
Will mo applicant or fumm building auupant mo equipment or devise which
emit hasaNnu, airconaminanu u defined by me Bay Amo Air Qwllly Management
all new materials for inspection.
Dimict7 11
OYes (.�rlu
I hew reed the huartlsms materials requ iremew under Chapter 6.95 of the Geller.
ria Health& SafetyCodc, Sections 15505, 25533 aro 75534. I andcom nd dnlf the building
does on, currently Mw a nouns that it is my rt,punsibilitY a mdfY the aalntpYd of cow
mqulmmenuwhicIt be met prier mimmanm afcrrle._afac��
of Applicant Date
2�L0—Signature
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All roof coverings to be Class or better
Owner Mer W mOrl2d agent Daa