04090080 77
CITY OF ClJPERTINO A,7 K n r ' I '- -
BUILDING DIVISION PERMITxCOiV•`CRACT.ORnINFORMATIO
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BUILDING ADDRESS: CLIFF W COUEY CONSTRUCTION PER.IT..04090080
843 T.TTY All
OWNER'S NAME: PERMIT ISSUE DATE
SADHANA GU21A 7608 WATERFORD DR /2
E: SANITARY WCr C NTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Oo LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm ,1 am licenxd ander pmviaious of Chapter 9(commencing
i� with Sec' n]O(Xl)of a' 3eTtY�gusince`uq Prafcssimu C antl my license is
^may in 1011 to b••r
Sqz Lieenaeels Lf.al ADD 158 S . FT. (KITCHEN) /REMODEL
z p v Cunvacmr
"F L) ARCHI'IECI'S DE N
re 1 understand my plans shall be=it u pubic ria
OyU
CG Licensed Pmfedi...I
g OWNER-BUILDER DECLARATION
'i Y I hereby aRrrn Nat 1 am exempt from the Contractor's License Law for the
(]O following mason.(Scetion 1031.5,Business and Professions Code:Any city or county
$ which requires a permit in construct,arm,.improve,demolish,or med,any structure Q0000
Fi< prior to its issuance.also requirrs the applicant for such Permit to file a signed statement
that ht is licensed ptiourm to the previsions of the Contrwmrs Lice.Li.(aaPICr9 Sq. Ft. Floor Area Valuation
w�a (commencing with Section 7X1))of Division 3 of the Business and Professions Cmlepo
he,he is exempt therefrom and the basis for dm alleged exemption.Any violation of
Section 7031.5 by any applicant foran a permit subjects she applicanun a civil penalty of. 3 5"�LI'QlDr0er0 0 O Occupancy Type
rap,mom Nrive hundred dollars(SKXn.
I,as owner of the property,or my employees with wages u their sole compensation, - \
will do she work.and Ne sometime is not intended or offered for age(Sep.7(144,Business
and Professions Code:The Convector's License law does no,apply in an owner of Required Inspections
property who builds or improve comon,and whodoessuch wart himself or through his
own employers,previded that Such improvements we not intended or offered forsale.If,
however,the building or improvement is sold within one yew of completion,thc owner-
' builder will bare the burden of proving that be did not build in improve for purpose of
salt.).
❑1.as owner of the property,am exclusively connecting with licensed com emrs to
construct the project(Sec.7044,Business and Professions Code:)The Conrracter s Li.
come Law dors not apply in an owner of property who builds or improves thereon,and,
who curtness for such projecss with a eomanew(a)licensed pursuant to the Convam e,
ip se Law.
1 wo eacmp,under Sec. .B&P C for this reason
Owner Dat
WORKER'S COMPENSATION DECLARATION
I Mreby aRrm under penalty of perjury one of the following declarations:
1 hate and will maintain a Ccnifn¢of Consent to self-insure for Workers Camper.
sa,ion,aProvided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued.
0 1 hale and will maintain Workces Compensation I....as myuimd by Section
3700 of the labor Code,for the performance of the work for which this Penni,is issued.
My Worker's Compensation Insurance caner and Policy number am:
Policy No.:
CERTIFICATE OF EXEM MON FRORSWORKERS'
COMPENSATIONIN_SURA�CE
(Thntaccu n raced net he comPlcted if rhe p ra i,is for..hundred dollars(SIXO
m less.)
1 ccnify that in the performance of the work for which this permit is issued,I shall not
employ any person in�ppray ma� nie ah Mmmc subject m tM Workers'Compensation
Laws of Cali�iCgm�a IYyGY
Applicant PLI II .
NOT
TO APPLICANT.If, making this Cisions of of Exemption,Code,y should
bac a scomp m rho Worker's Compensation previsions of,hc ruedLabor
ewski you must
.Jz with comply with such pmvisiom or Nis permit shall hdcemctl mvotcd.
Z OCONSTRUCTION LENDING AGENCY
'r+(+ I hereby afros Nat there is a construction lending agency for the performance of
Cthe work for which this permit is issued(Sec.3097,Ci,C.)
W QLcndcfs Name
P. Lender's Address
a Z
V Q 1 certify On,l have read this application and sea¢that the above information is -
lL r coned I agree to comply with all city and county ordinances and sum laws relating to
p V building construction,and hereby autboma representatives of this city to orator upon the
ra above-mentioned propsny for irepemion pupoks.
(We)agree to save,indemnify and keep hafmless the City of Cupenino against
FN Imbilitie,psigmmos.costs and apertses which may in any wayaecrceagwnst said City
U Z in comahumme of the granting of this permit.
^ APPLICA UNDERST DS AND WILL COMPLY WITH L N POINT Issued by: Dale
SOURC-5+'QU�`TIOU�
v '91.
/ L� Re-roofs
swum of AppliunVCon Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building reception amore or handle hwardous material
as defined by,M Cupertino Muni ipal Code.Chapter 9.12,and the HuLO and Safety
Code,Scene.25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or It b iimn r ore t or devices which If a roof is installed without first obtaining an inspection,I agree to remove
g oceupan cyuipmcn
it hvardous air contaminant lined by the Bey Area Air Quality Management all new materials for inspection.
District P
❑Yes Nu
Ihavemad Ochur wsmawhalsmquimmenuunder Chapter G95ofthe Califon
nia Health&Sdcly Code,Sections 25505,25533 and 25534.1 undersand thB,if the building
oMS m avC a ICNnI, l li my RspOmihi ily m nr)dly Ile 0.0..1 of the
myuiremcum�hmusrpe prldia4.anee.ra cerdrealeyo-ge wokSignature of Applicant Date
owner. a.mnnrim<'d_lasJ/n `, ,.ice All roof coverings to be Class"B"or better