06040184 CITY OF CUPERTINO �7 17:`"' `
BUILDING DIVISION PERMIT ..aC:ONTRAC�TQR IPTk'QRMATIO.N-
Y•ft+t x n M•v:',. qua
B UILDING ADDRESS: • I SINGH PE@MIT NO.O6O40184
1079 NOVEMBER D
OWNER'S NAME: PERMITL'SUEDATE
4MI SINGH 07/03/2006
NE: SANITARY NO. CONTROL NO.
ARCHRECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
10o LICENSED CONTRACTOR'S DECLARATION Job Description�u 1 thereby affirm that 1 am licensed under provision of Chapter 9(commencing
Z with Section 7g10)of Division 3offt Butinwand Profession Cnde.and my liceneis
+�< tnpoll fineeemaffect. SFDWL ADDITION FAMILY ROOM 471 '
Z License Clan Lim.g
Dau Contractor
ARCHITECTS DECLARATION
e I understand my plan shall he used at,public records
.Q Licensed Professional
OWNER-BUILDER DECLARATION
g 1 hereby 417".that I am exempt from rite conuacmra License Law fat the
2 o O fallowing roman.(Section 713 1.6,Business and Pmfrscon Cade:Any city of county
5$ which nal a permit to consumer,glass.improve,demolish,of repair any structure $100968
prior to its issuance,also requires the applicant forsuch permit to file a signed statement
< that he is uccroad pumtant to the provision of the Conttstor's Lieetua Law(Chap.9 Sq.Ft.Floor Area Valuation
r�D (commencing with Section 7000)of Division 3 of the Business and Protestors Coda)or
$ that he is the basis far the alklod
1A by any applicant eam far a permit the applicant on.Any viota�om of
Section 703itt Io a civil penall of
Occupancy Type
not mart than five hundred dollars(SSW).
0 1,u owner of rho pmpossy,m my uwployca withwage u theh sok comperuadon,
Will do the work..4mor swct..k notimm�dm-ranertd fm We(Sa.70a4,Business Required Inspections
and Pmalo
fesn Code:The ComranoYs Littn to me law doant apply an awmr of q P
Property won builds Or improves rhon on,and wbodoessuchwork Immelfm Uuwugh his /
ownemplay ea,provided that such improvemenu art net intended"offered farad&U.
however,the Wilding or Improvement is sold withinae year of completion.the ownu-
bulldu will have the human of proving But he did not Wild m improve for purpose of
uek.I. /
ce 1.u ower of the Sm 7 .B slummii and cmta¢ting with licensed ammuacnm - `_J—!
come La the es Out (pleaW in anions and ny who
Cede:) pro COOYLLbra LI-
who cave dna not such
a to wither Of propenY wbo deolds m improm Norton,and /
whocontractsforauch POKce with emntncrar(s)Ikmxd Punumtm the Canvactoh
01MUw.
❑lam semDt under Se .B&PCfar this mam, 1
Owner I y Dau M 411 yO
Oil 5 OM RATION
I hereby afRrso under penalty of my an of me following dulandom: Z
❑1 ham and will maintain a Certificate of Conant in slf-inmrt far Worko'sCampen-
stum,as provided for by Section 3700 of the labor Came.for the performance or the
work for which this permit is issued.
❑1 have and will maintain Worla's Compensation Inmnnca,a required by Second
3700 of the labor Came.for the performance arms,work for which this permit is issued.
My Workm's Compensation Insurance carrier and Policy number am:
Cartier. Polley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This acmen need notbocompkred Use pernit lafmoe hundred dollen(SIM)
or legal
I certify met In me performance of the work for which this permit Is blued I shall nm
employanypetsoninsymmrer as ohecam subjec mute Workers'Campenaation
Laws of Calif" D ,.,F—+
Applicant •nom
NOTICE TO APPLICANT.If.afar r a mg this Certificate of e Labor
d you Noun .
baomeh comp m the Wanted Compensation provisions of me labor Cade you most
.7,O forthwith comply with such provisions m the permit shall W damn revoked.
q tiCONSTRUCTION LENDING AGENCY
I-n I hereby a fl m that there k a eonm emat lending agency for the performance of
C>
Its:work far which this permit is issued(Ses.3097,an.C-1
�W Q Lenders Name
z Leaders Address
U 0 1 certify that 1 have mad this application and sum that the above Information U
W F cwaccl.1 agree to comply with all city and county ordinances and sou laws relating on
DUbuilding eonsuuction,and hereby amhoria s
reprenuupon the
of this city no enter uthe
W above-menuuned properry In,irupecuan purpous
gy (We)agree to save,indemnify and kap harmless the City of Cupenino against
res
liabilities 3udgmem,costs and e.K.which may In any way aceta against said City
IJ 7 in canaequenco of me gestin{of this permit.
t1• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE NSA{�++
a.f 16i _ It/, 1w� mob. Re-roofs
Sig sum of Ap lino s t Date
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building acmupanutos arhandle harallous material
as defined by the Cupertino Municipal Code.Chapter 9.11,and Ute Health and Safety
Cale,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yn ®No
Will the appncarn or future building occupant um equipment err deviceswhich If a roof is installed without first obtaining an inspection,l agree to remove
emit hwnNnm airconuminnu as defined by the Bay Ams Air Quality Management allnew materials for inspection.
District
❑Ya ON.
I have mad me haaaNnu materials rtquimmenks under Chapter 6.95 of the W ifor.
nig Halm&Safety Code.Sessions 25505.25533 and 25534.1 undermost that lfdm Wilding
does not currently have a tenant,that it is my nupomihiiby to nodfy Ute accupm,of the
requimmenu which must beIpdortoZ roma of CctUncamorOcapmmy Signature of Applicant Date
f
Owner m oulbodaed agcn, - Dam All roof coverings to be Class"B"or better
l