11060196 CITY OF CUPERTINO BUILDING PERMIbATE4Z ?-�!
BUILDING ADDRE&S: 18970 NEWSOM AVE CONTRACTOR:SAMPAT SHAILESH& PERMITNO: 11060196
BHAVNA TRUSTEE
l 'S NAME: SAMPAT SHAILESH&BHAVNA TRUSTEE 7181 STOESSER CT DATE ISSUED:08/31/2011
OWNER'S PHONE: 4089276631 SANdOSE,CA 95124 PHONE NO;
❑ LICENSED CONTRACT'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB F
License Class Lie.# r -TIAL F
MECII RESIDE
COMMERCIAL
Contractor Date
hereby affirm that 1 am licensed under The provisions of Chapter 9 JOB DESCRIPTION:CONSTRUCT(2)STORY SFDWL 2,550 SQ FT W/A*17ACl1ED
(commencing with Section 7000)or Division 3 of the Business&Professions GARAGE 406 SQ FT-SANITARY IS SUNNYVALE'S
Code and that my license is in full force and effect. JURISDICTION
10212011-DEFaI-DEFERRED TRUSS CALCUATIONS-11282011 DEFHI ISS'D
hereby affirm under penalty of perjury one of the following Two declarations:
I have and will maintain a certificate ofconsent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$300000
permit is issued.
APPLICANT CERTIFICATION APN Number:37535014.00 Occupancy Type.
I certify that I have read this application mid state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section p
9.18.
Issued
Sore Date
lY !;
Olt OWNER-BUILDER DECLARATION
RE-ROOFS:
hereby affirm that 1 am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: - installed without first obtaining an inspection,1 agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant:_ Date:
1,as owner of(lie property,am exclusively contracting with licensed contractors to
construct the project(Sce.7044,Business&Professions Code), ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations: I1AZ RDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilealth&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should 1 store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
pernin is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,l shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safely Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,alter making(his certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must h d agent
Owner or a,, ooze
forthwith comply with such provisions or this permit shall be deemed revoked, j' Dat
P Y P P �-rtt:�;r t.
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree no comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
..*he above mentioned property for inspection purposes.(We)agree 10 save
ify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
and expenses which may accrue against said City in consequence of the
granting ofthis permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18, V, I understand my plans shall he used as public records.
fSigna"tura�l Pig upy.�'a, '(',"-"q' t ""' Date Licensed Professional