04120154CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
VARADACHARI RENGARAJAN
PERMIT NO.
04120154
OWNER'S NAME:
PERMIT ISSUE DATE
PE:
SANITARY iftOL NO.
ARCHITECTMNGINEER:
BUILDING PERMIT INFO
BLDG E12LT PLUMBMECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
o
licensed under provisions s of Chapter 9 (commcming
I hereby affirm that I Am W
P
with Section 700) of Division 3 of the Buenas mud professions Code, and my license is
in felLest. 0. d enecL Lle0
ADD 1281' (FM./KIT./MS.BED & BATH)
Dam—Contractor
GARAGE 468'
ARCHITECTS DECLARATION
1 undemwnJ my plana sheik he used u puM1lic rccnNs
L'a:onmd Professional
OWNER-BUILDER DECLARATION
� ������
I hereby alarm that I An exempt from Use Canu is oh License law for the
following moron. (Section 70313, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve. demolish, or mpoir'my Nuctum
poor in its issuance, atm requires Ne appllaut formich permit in file a signed matement
that he is licensed pursuant as the provisions of the Conuacur's License Law(Chapter 9
Sq. Ft. Floor Area Alb
Valuation
(commencing with Section 700) of Division 3 of the Business and Professions Code) m
Nat he h exempt therefrom and the bash for she alleged exemption. Any violation of
Section 701.5 by my applicant for a permit subjects the applicant ut Advil penalty of
APN Number
cy Type
norm Nan Rus hundred it Ilan (ML
u owner oftide progeny, or my employer AIN au their eir role compensation,
3 5919014.00 Required Inspections
illelothc work, and Neswnumhnatinmndedwanemdfwu (Sec.70LBusinen
and Profession, Code: The Constitute, License Law docs not apply b an owner of
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property who Wilds or lmpmveaUmman.aMw utdoessuch anrkbdmselforthrough his
own employees, provided th&uuch improvements are notimended aronered forme If.
however, to building or improvement is mid within oro year of completion. the owner.
builder MB have the buden of proving that Ise did net Wile or Immune for purpose of
sale.).
❑ 1, as ver of the property. Am exclusively connsi wish licensed conn esm, to
construct the project (Sec. 70th. Business and profaslans Code) The Contractors Li.
come law doe not apply to an owner of property who WIWs or improv thenen, and,
who contracts forsuch projects with a conlnom(O licensed pursuant to the Comnctota
License Law.
❑lam .Bk PC for Nh mason
ism
Owns l/Q_�V1 — a+� Dam
— WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury on: of the following declarations:
I haw and will maintain • Certificate of Consent w self-insure for Worker'sCompcn-
Muan, u prmlded for by Section 370 of she Lather Code, for the performance of the
work for which this permit is iutmd.
❑ 1 law roti wiB maintain Wotrr1 Compensation InNrmma. u rtquired by Section
370 of Ne Labor Code, for the performance ofthe"At for which this permit is issued.
'
My Workeea Cnmpensauon Insurance card. and Polity number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(ITis section used not hecompice d If tiro permit is fnarchundred dollan($10)
m less)
1 anify that in the performance of Me work for which this permit is blued, I Nall not
employ any person In Any manMrm as m hCCOTC Nbjeel moth Worker' CompenanM
LAWS of Cali
Ayplle.
NOTICE APPLICANT`. If. After making this Cmificne of Exemption. you should
become subject In the Worked Composition provision, of she Labor Code. you mus,
forthwith comply with such pmvWou or this permit shall be deemed rewked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that Nem Is. construction lending agency I'ar the performance of
Ne woh for which this permit h issued (Sec, 309'1, Civ. C.)
`
iandeea Name
Loder'. Md.
1 certify that I haw mad this application and mm that the &bow information Is
'
comet. l agree in comply with all city and county ordinances and sum law, relating In
Wilding construction, and hereby authorixe representatives of this city rooter upon she
,how-mentianed pmpeny for inspection purposes.
(We) agree to save, indemnify and keep harmless she City of Cupertino against
liabllitia,judgmenu,com andexpemes m
which may In my way au, against Mid City
In consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURC U CATIONS. �)
Re-roofs
Type of Roof
SigneNm of Applies- Dem
S MATERLALS DISCLOSURE
HAZARDOUS
Willy applicant or future Wal Cg oceupmt rnm or Medic M1 material
ealloes
As defined t Municipal Cade. Chapter 9.12. roti the Health and Safety
the
Code, Session 3ss33(.)7
io 32(.)?
❑Yes RNu
All roofs shall be inspected prior to any, roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hmNaus Air conuminanu as dcRned by the Bay Area Air Quality Management
all new materials for inspection.
District? `
[:1 Yea ;111 111
IhewroW the haurdmmsmateriats requimmenu under Chapter 6.95 or the Cantor.
't
niceHai&Safety Cade. Sceuons 35505.35533 and 25534. Itualouid NU lftim Wilding
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dace not curmmly hew a mnmt, the It is my reasonability in notify Um occupant of Ne
requirements which mum Imt prior to tasama an cenirm&m ar(kapanry'
Signature of Applicant Date
2
All roof coverings to be Class "B" or better
wnerorauthorixeda cn, pte
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