04090242 C[TY OF CUPERTINO �ilLS
BUILDING DIVISION pEg1�T CONTRAC�°T•.O INFORMAT79 '
BUIL DING ADDRESS:., SUGI LONGANATHAN PERMIT N004090242
OWNER'S NAME: PERMIT ESUS DAlB
i- E: SANITARY N0. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
3oii
LICENSED CONTRACrOR'SDECLARATION ]obDescription o O
1 hereby affirm that I Am licensed under provisions or Chapter 9(commencing
zz wish Section]IXI0)efDivivan 3ofshc Buurcu and Profession Code,and myllcenm Is
^! in full forte and enecL
gg_ ucenmaaa �,g SFDWL-2 STORY (2543 ' LIVING)
x ate ARCHITECTS DECLARATION
BASEMENT 622 ' /GARAGE 441 '
1 understand my Plana shall E TS As public records
Licensed Professional
OWNER-BUILDER DECLARATION
f 1 hereby aMm that 1 am asempt from ilte Contractor's Lignac Law for the
00 fallowing ream..(Section 7031.5,But.And Profasaluns Code:Any city ar county
I� which requires•permit in crummuet,eller,improve,demolish.or repair any structure
prior to its issuance.Alm requires the applicant for such permit In file a signed statement
that he is licensed inclusion aumprovision ofthe Common's LicenseLaw(Chapter 9 Sq.Ft. Floor Area Fga�1Va ..
63 a^ (commencing with Section 70D0)of Dlvuan
ion 5 of the Business d Professions Code)or V 3814" 0
�'t 3 thn he is Attempt thaefmm and the basis fm dm alleged exemption.Any violstnn of
Section 7071.5 by any.ppuaant ren•permitmbJecer the applicant m a civil penalty of AN Number Occu .
Type
notmart Nan In hundred dolWs(M
❑I.ssmwlmrofthpmpmy,mmyemployrsawiNmpsudte mkcompenudon, vIlt
will do the work,and the monsoon is not intended or offered far sale(Sao 701/,Bualnm Re uired Ins ecdons y .
and Profecaiea Code:The CaniramrY License I.Aw does not apply to An comer of q p y
propenywho WIIN orimprows Nemon.and whodoessuchwmk himselforthenugh his
owmempmyees,pmvided thatsuch impmwme ss are notintended mattered fmcsk.U,
however.the building or improvement Is sold within oro yea,of completion,the owner. .
Impose will low ten burden of proving mat he did not build or improve fm purpose of
Asia.).
❑1,as owner of the property am exclusively contracting with licensed canaaman as
construct she pmJen(Sec.7014,Business and Professional Cade:)The Contacmr's U.
cenm law dens mat apply in m owner of property who builds ar improves thereon,ad
who cantmcu for such pm)em wish a eantractm(s)licensed pursuant m she Contractor's
License law.
❑]amescmptu dor SecB&PCf NI mann
Owner Data ^
WORKER'SCOMSATIONDECLARATION
1 hereby Affirm under penaltyof peOury enc of the following declsntiaa:
1371WO
haw and will maintain a CoNOnte of Consent m self-laum far WorkarsCompen-
,As provided fm by Section 7700 of the labor Code,for the performance of the
for which this permit is issued.
haw and will maintain Worker's Compensation Insurance,a required by Section
of the labor Code,fin the perfamunce of the work fm which this pemti(is Issued.
Worker's Compensation Insurance tinier and Policy number Am:
CaMm Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Trim Acca need not M completed If the permit Is reserve hundrt4dellan($lmO
or less)
1 certify Nn in the performance of Om work far which this permit is issued.l shall not
employ any person in my manncry In ce�lcwbjectmtie Warken'Cmmpensatan
laws of California.Dam
Applicant J !y
NOTICE TO APPLICANT.If,after tf m,this Certificate of Exemption,you should
become subject in the Worker's Composition previsions of the lahm Code,you must
,J O forthwith comply with such provisions"is permit shall he doomed!maked.
.E.t M CONSTRUCTION LENDING AGENCY
(-r (hereby afl7mt Nn thte is a construction lending agency far tis performance of
6i w�-r
the work for which this permit is issued(Sm.357,CIv.C.)
WQ Lender's Name
�
,a z Lender's Address
C)Q 1 certify Inas I naw mad thisApplicationand
mrd auk wt and
show mmrm•Ilan is
LT�0 h•" buried 1 agree uc comply with all city and county ou i ves of and cute rows relating m S
0 Alsom-gendonedoaand herby auNonatposes. tatiws of Nu city mcnter upon tis
Nd shove-(Wtion agree
to xnysaw,for lapenian keep ha
FC+'
(We)agme to cave,indemnify and keep humlw theCity of Caperton against
rq
liabilities,Judgments.calls expenses which may in anywry acme galas aid City
V`1 In consequence of the grating of this permit. V
Fl APPLICANT UNDERSTANDS AND WI�L��QQMPLY WITH ALL NO -POINT Issued by: Dae
SOURCE 9EGUl�AF191gjD. ^ �,(/ r' �II 7O/ Re-roofs
Signa of ApplicanuComtsanor /�^ ate l
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tiro applicant or forum building occupant store or handle huamous material
As Nrmd by the Cupertino Municipal Cade,Chapter 9.12.and she Health and Safety
cash,Schen 2ssu(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑Nu
(- Will she applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,l agree to remove
1 t haardnus Air contaminants As Corned by the Bay AMA Air Quality Management all new materials for inspection.
District?
❑YU ON.
I have mW the hmarNms materials requimmanss under Clmpter6.95 of the CAUCA. '
Ads Haul"Safety Cade,Sections 25503.25577 ape 25534.1 undermost druif the Wilding
door not currently haw a annual that It k my responsibility m notify the -pant of the
requimmcry mento 'armiutaneca .Cortlof'ce cn rSignature ofApplicant Date
Owner or authodmd age wC7 te� All roof coverings to be Class"B"or better