04080246 CITY OF CUPERTINO
BUILDING DIVISION PERMITC1N'T12AG.lt`Q�2. M'' I�'M^�TrQ �.'�• '
BUILDING ADDRESS: PHAN CONSTRUCTION CO INC PERMIT N004080246
10404 MENHART LANE
OWNER'S NAME: FISEMPI SSHEDATE
ANBUKARASAN TAMIZHMANI 870 S WOLFE ED
E:
SANITARY NO. CONTROL NO.
(408) 737-8323
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
400 LICENSED CONTRACTOR'S DECLARATION
�u 1 he by affirm Nat 1 am licensed under revisions of Chapter 9(commencing Job Description
' with Sc6ti9d�P]O(lo)of Divialon3afihc Basins, nit Profcssi...Cnde,andmylieemois
^ � infullralttendeffer 3
.oil REVISION--FOUNDATION DETAILS
5 z LicenmCly —Lio.a 12. C"4_701KAI '91 [s • NO NEW PERMIT ISSUED/ ORIG. #03040067
n F,— DAM Cmoracbr
ARCHITECTS DECLARATION
1 underaURV5y Pam i shall be used as public men ch,
6
;p Licensed Pmfcsai0nel
OWNER-BUILDER DECLARATION
0 0 I hereby.firm onthat I70 1. exempt Imre me tractors Co License Law for the !moi
p o following mason.(Sadao IID LA B. he,,
andmpr nst,Protractors Cade:Any city or county
K$ which requires a Irnnit m cnnstrves.cites improve,demolish,or repair any atrvctum
'o prior to its issuance,alw requires meapploxnt for such permit to flea signed awtemem
-Z�xt that be is licensed pursuant to the pmvisinnaof the Con(mcar's Llan.Lw(Charter,9 Sq.Ft.Floor Area S Vajigzo)0000
an (commencing with Sec(ion]000)of Divixion]nf NC Businvsend Professions Code)ur
R.. That he u exempt therefrom and the basis far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant 10 a civil penalty of APN Number "QCd9WCy Type
Out mom Nan five hundred dollen($500). 37516005 . 00
❑1,m owner of the pmpxmt,or my employees with wage v chair sole compenmdon,
wllldorhework,and Neanucture is not intended ordffered fmade(Sec.7044.Business
and Probations Code:The Contractor's License Law does not apply to an owner of Required Inspections
property,who build i or Improves merson.a nd who does such work himaelf or through his
own employees.Provided that such improvements art not intended Or Offered for sale.If.
however,the building or improvement is sold within one year of completion.the owner.
builder will have the burden of proving Net he did not build or improve for purpose of
mac.).
❑1,as Owner of me property,am exclusively contracting with licensed contractors a
conswct the pmjeat(Sec.7040,Business and Protests.Cotler)The Ci mmounts U.
cave Law fires not apply to an owner of property who builds or improves thereon,and
who comment for such projects with a comoscim(l)licensed pursuant in UUn Contractor's
License I.
O l am exempt under Sec. ,B&P C for this mason
Owner Date
WORKER'S COMPENSATIONDECLARATION
J` 1 hereby affirm under penalty of perjury one of the following duclantions:
`-� have and will maintain a Ccnifivls of Consent o self-insumfor,Worker'sCompen-
on,as provided for by Section 3700 of the Labor Cade,for the performance of the
work for which this permit it issuctl.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37110 of me Labor Code,far me performance of the work for which this permit w issued.
My Worker's Compensation Insum rce carrier and Policy
number am: '
C.
'err: ST.ffT�' �UNn Policy ry¢: 2rs -2oa�'
CERTIFICATE OF EKEMPf10N FROM WORKE99
COMPENSATION INSURANCE igS�ry4ag,.4
(This section need notersomphood lithe rental,is fusion,huad dWkd9TrrW_)
m IesaJ
1 certify that In me performance of lie work for which chis permit is issued,I shall not
employ any parson in any manner.at m become subject to the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
became subject in the Worker's Competuetion previsions of the lahor Code,ynu mux(
0 forthwith comply with men prevision or this Permit shall be deemed revakcd.
„ziCONSTRUCTION LENDING AGENCY
y
,S I hereby aRrm that mem is a construction lending agcnry for the Performance of
a > me work for which this permit is issvd(Sec.3097,Cl,C.)
IL) 0 Lender's Namc
z Londeea Add.
U0 I certify Net 1 have reed this application and nate that the shave information is
0. PCorrect.I agree to comply with all city and county ordinances and awls laws reaming In
O building construction,and hereby summons representa(iwat of this city to enter upon me
G above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
o-F.t N liabilities,judgments.costs and expenses which may in any way accn,against mid City
U in conaequencc of the granting of this permit. ,
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POI ]' Issued by: Date
SOURCE REGULATIONS
Y i A//VJ�7 Re-roofs
( Wm of APPlicantl onRe�
DOU /7
/ HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building e,Chart nom or handle Health
material
as de,See by the Cupertino Municipal Code,Chapter 9.17.and the Hcalm and Safety
Code,Section 75577(.)? All roofs shall be inspected prior to an roofing material beim
❑rns ON. P P � Y g being installed.
Will the applicant or future building occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hamobous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
40c,cl?
Oyes ON.
I have mad the havrdouseraterialsicquimments under ,Chapter 6.95 of me Califor-
nia Health&SafctyCedc,Sections 75505,75533 and75534.1 undersand thmi0he building
docs not cunenlly have a Unions.Nat it is my mapensibility to sea
occuPmt of me
mquiremc9wwhich most be met pndrto issuance of.Cenifum,o Cr y. Signature of Applicant Date
o All roof coverings to be Class"B"or better
,Owner or mthorrgcd figcntf- I Date I