06010125 CITY OF CUPERTINO 0m tz'6p-
BUILDING DIVISION PERMIT '�CONTRACTORINFORMATIONa ;
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BUILDING ADDRESS: ASHISH KOTHARI PERMITNO.06010125
10490 MIRA VISTA AV
OWNER'S NAME: PERMIT ISSUE DAIS
ASHISH KOTHARI 01/30/2006
E: SANITARY NO. CONTROL NO.
ARCHI'ECTIENGINEER: BUILDING PERMIT INFO
BO ELECT PLUMB MEOCH
300 LICENSED CONTRACTOR'S DECLARATION JbDescription
1 hereby affirm that I am Mounted under provisions of Chapter 9(commencing o
with Section 7")ar Division 3 often Business and Professions Code.and my firms,is
I.fun mree and effect. ADD 4451 (FAMILY. ROOM)
q Z License Class U..
oilDate ARCHITECT'S DECLARATION
I udecnumT my plans shall he used as public records Ap'
e, ,sensed Professional50� OWNER-BUILDER DECLARATION
8�9A
w�tv�
f f i I hereby aRrm ROP
that 1 am re crept from t e Coractars License Law for the
00 following reason.(Section 70313,Busimss and Professions Cade:My city or county
I� which requlrea a permit W consumer,alu.improve,dcmolish,or repair any swerum
_Zty' prior to is issuance,also requires the applicant for such permit to Ne a signed mumbot . •-
< that he Is licensed moumunthe prevision ofMeContractor's Licens,Law(Chapter 9 Sq.Ft. Floor Area ation
$ (commencing with Section 7")of Division 3 of the Business and Professions Code)or
that he is attempt Merryman and civ:basis for the alleged en ampma Any violadon of
Section 103 L1'b,ury,appllunt fw•permh aubjec'am"'
the appllunt to a civil pcoah"of r Type
not me than hundred dallms(5500). -
owner of tde proprny,army wploycns wIN vngus as thetrule mmpenudon.
Ivplldo Muwolk,mdlbeswttme6notinunded woRered farsak(See,7001,Businat
and Purchasing Code:The Conusc m's License law data tet apply to an owner of Required Inspections
property who builds or liniments Marconi who doessuchwork himsel(ar through his
awn employ.,provlded that such(mpmwments art nor hotbed wooers for sale IL
howcvsr,the building or improvement is sold within one year of completes,the owner.
Wilder will hate Me burden of proving that he did not build or impmae for purpose of _
sale.).
.u owner of to property,am eaclasiwly contracting with licensed convectors to
constmcl the project(See.7044.Business and Prefeaalons Code:)M coommu ..Li-
ante law does not apply to an awoer of property who Wild,or improves thereon,and,
who contracts for such projects with a conuaaor(s)licensed puruam to Me Convacer's
License Law.
❑I.. Pt day �r/�� _,, .Bal PC fmthbreason
mD r �Yaiy�""" K;�.( Data
WORKER'S COMPENSATION DECLARATION
or 1 hereby affirm under penalty of pedury an of the following declatWons:
❑Ibawsed will malnuin aCertlfiroua(Conanuoasl4Wure(orWorkcrlComp,n-
ss0on,n
wort, provides los Semon 3700 0(the lobus Code,Iw Ne perfarmana of the
for which N8 Permit is laa4 ,
❑1 haw and will maintain Workers Compensation Insurance,as required by Section
3700 of the Isbor Code,for the performance of the work four which Nis permit Is named.
My Workers CompensaOon imunna nrrler and Poliry numWr m:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This auction need not be completed If the permit is form=hundred dollen(5100)
or leu)
1 aAfy that In the performance of the work for which this permit is issued.l shall not
empfayanypenonlnany mann (o MCOlwDJatmde Workeri Caopeoudw
Lawsof Califom1, 0�1 g
Applicant /b w
NOTICE TO APPLICANT:IL after making this Cenifiwu of Eteminion,you should
become subject to the Workers Compensadon provismns of to Laem Cade.you mon
wJ 0 faMwith comply with such provisions or this permit shall he decmcd revoked.
.Z„ CONSTRUCTIONLFNUING AGENCY
f'• IherebY affirm that mcre iso construction lending agency for the perfurmamu of
P,a> the work for which this Permit is Issued sec.3097,Cih,C.)
Wh Q Imomes Name
Undoes
nders Address
U Q 1 cenify that 1 ban reed this application and sum that the show information It
corutt I agree a comply with all city and county ordinances and nam laws missing to
Wilding construction,and hereby authorize represcoutiws of this city to now upon the
W aWvcmendoned property for Inspection purposes.
(We)agree to haw,indemnify and kap hamtlett the City of Cupertino against
` 0 Ilabllitia,judgmenu,cwu and expenses which may In any way acerae against mid City
t) in consequence of the granting of this Permit 6'
APPLICANT UNDERSTANDS AND
�WILL
'COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RECUJ(/aTF �D WLIt
�'t Re-roofs
Signature afApplicmUCoARDOU Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII Na applicant or future building acuputstou or hazerdous material
as defined by the Cupertino Municipal Code.Chapter
the 9.13.had the Hulth and Salary
oda salon 21112u)? All roofs shall be inspected prior to an roofing material beim Installed.
Dy. m4rb P P Y g g
Will the applicant or future building occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hasrdous air comsenimmu n refined by the Bay Ama Air Quality Management all new materials for inspection.
District?
❑Yro GWm
I haw mad me bmndousmmr.Mabnqum menu under Chapmrd.95 of de Califor.
nia Hml"Safety Code.SecMau25505.25533end25534.Iun&YPAM eifthe Wilding
does not currently hew:a monk Net It u my remonsihility to notify the wcupmt of the
mqm coat wnic mismancc of a cenincam of Occupancy. Signature of Applicant Date
Owner or ammoti zed agent Dam All roof coverings to be Class"B"or better e-