05090175 CITY OF CUPERTINO
BUILDING DIVISION P$RMj'j' iCONTRACTgR INFOIt AT70N ,
BUILDING ADDRESS: PERMIT NO.0 5 0 9 017 5
19147 LOREE AV
'ER'S NAME: PERMIT ISSUE DATE
ROYALA, DEEPIKA 09/27/2005
PHONE: SANITARY NO. CONTROL NO.
ARCHITECrIENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
30p LICENSED CONTRACTOR'S DECLARATION O O O
4 1 homey aMo.that 1 sm licensed under provisions of Chapter 9(commencing Job Description
i infafdon7011,11mDivision3oftheBualnwandPrefesalnnsCode,andmylicensu REMOVE MSTR BATH STALL SHWR WALLS AND RESTORE
^< infull tome aM e)of v'
DDamnmOm cow DAMAGED WOOD MEMBERS, WALL FRAME SUB—FLOORING
AA1CRrMCrs DECLA
1 undcnund my plans shell W wed as public records
D�Q
g G Licensed Professional
OWNER-BUILDER DECLARATION
y I hereby affirm that 1 am exempt from the Comrselmrs License Law for Ne
C Oo fallowing moon.(Section 711313,Business and Professions Code:Any city or county
3IRE which requires a permit to mnsma,alter,improve,demolish.no mpoir any numum
Fprior to its issuance,also requires;die applicant forsuch permit to file a signed st mmem
g< that he is licensed Vermontin the provisional ofNeCanuacmriLhxnse Law(Chapter 9 Sq.Ft. Floor Area Valuati
$ (commencing with Section 700(1)of Division S afthe Businessland Promotions Code)no
Q .. Nn he is eaempl dumfrom and the basis for the alleged esemp ion.Any violation of gpy7���f7..;TtJf�1y,�
Section 7071.5 by my applicant for a permit Objects Ne appliesnt o a civil Knotty of 3 /7 V /V-$Ve. 00
Occupancy Type
not mom Nan five hummed d.11m;($500).
❑I,as owner of the property,or my empioym,with wages at their sole compensation,
will do the work and the,trucwre Is not intended oroffemd pertain(Sec.7041,Business
and Pro(wiona Cade:The Conumehr,Lmem s law dose rot apply to in owner of Required Inspections
property who
yees.provided
thatsuhImprovements
mprandwht me anch t imwork himselfor feredmuough his
ownemployees,praNhd that such ImPro id wham em intendedmoRnM for Moll If.
however.Ne building w Improvementisveld within ane yam of conspicuous,provfor
the owe of
builder will have Ne burden of proving Nal be did not bald or improve far purpose of
.I.I.
❑I,as owner of ct property,.B ex assns d contracting with licensedTheCeontram's U.
monaLtrideesakm(Sec.o an mmor ofsandrty who
Code:) pr es;damns. d /
who clawdoesnotapplyots with
of property whobuildsor alto the
damns.ad. j
whoco Law.for such projects with aconuunar(q Ilmmed purswnlo Ort ConuxlaY. j
Linens law.
❑Tem exempt under Sec. ,B&PCfor this mason Gam/
Dau �O
WORKER'S COMPENSATION DECLARATION
I hereby&Rhm ander penalty of perjury am of tbe following dechustioes:
❑Thaw and will maintain a CerdRcemef Comenl to self-Insure for Workers Compere
anden,an providad for by Section 7700 of the labor Code,for the perforromm of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Inswanm,as required by Section
3700 of the labor Code,fm the perforations:of the work for which Nis permit is laved.
My Worker,Co Pe atim la nm nim and Policy number me:^
Carrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERT
COMPENSATION INSURANCE
(Thu section need not be camp f eted lithe Parma Is far ane hundred dolhoo(SIM)
m kis)
1 coni[that in the performance of the work for which this Permit is intend,I Mall not
employ any peon in any manner m u to become subject to the Workers'CompenMotion
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccmricaw of Exemplian,you Mould
become subject to the Worker,Com,s notion provisions of the IaMr Code.you mum
.J 0 m
forthwith comply with such provisions or this permit"I W deeed corked.
Z rM CONSTRUCTION LENDING AGENCY
f'^ I hereby affirm that them is a construction lending agency for the perrormom of
aithe work for which this permit is lurem.d(S 3097,Civ.C.)
G0 Lenders Form
,7. lender.Address
U 1 mnify that I have mad that application and sum that tis above Information is
IL contact.1 agme in comply with all city and county ordinances and soon law,reading to
0 U building construction,anal hereby authorise mprosnotives of this city to enter upon Oe
137 Move-mentioned property for Onpedon purposa
py (We)agree to Move,indemnify and keep hamlets Ne City of Cupertino Against
yz liabilities.udgmeau,cmu and expenses which may In any way amen aPWtsid City
A1Win cc U^�
UU(DfEj,flN"DSA1D WILL COMPLY WITH ALL NON-POI Issued by: Date ARe-roofsliwnUC n Dau
XAZA ATERfA1P DISCLOSURE Type of Roof
WIIl rite appllmnto 1 Ilding mupant momahaMk herudou.material
defined by the Cupen,a Mu cipal Cade.Chapter 9.12.sod the Health and Safety
.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yea No
Will the applicant er fou bulling amapam use equipment o,devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harardoos alt cnnumin, as dcNmd by dm Bay Ama Air Quality Management all new materials for inspection.
District? _
❑YesNo
Ila vent thehva"2,5 ,!2,,y3u3'!
nu un@r Chapter 6.95 of NCCalifan
nia IN sae C ,S5574.iundanond thulf the building
d talc nal have ibilityona0fy u Let
no sur B h lie, Signature of Applicant Date
owner ..than d ase Dam All roof coverings to be Class "B"or better