02090039 CIBUI DING DDIVISION
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMR NO.
10225 ORANGE AVE. CHARVEZ CONSTRUCTION 02090039
oS � PAM VEMULAPALLI 360 W 8TH ST APPLICAO9)06UB A%2002
HONE. (408) 893-7693 SANITARY NO, CONTROL NO.
O O ARCHITECT/ENGINEER: s BUILDING PERMIT INFO
E BLDG ELECT PLUMB MECfi
�iy
LICENSED CONTRACTOR'S DECLARATION
i job Description
O Z✓� 1 hereby affirm @m 1 um licensed under provisions of Chapter (commencing REVISION--IN HOUSE USE ONLY
�mtaa with Scnion T000)of Dishom.3o(the Rusinessand Professions Code.and my lice.
is in funrareeand)effect. ORIGINAL #02020090
�s a Date Cl... Lie.« REVISION SUBMITTED ON 07/15/02 (402070084
a�3 !w Dam Lic.is Contractor
ARCHITECT'S DECLARATION
z2 to I I understand my plans shall be used as public records
�a atg p Licensed Professional
A o 2 OWNER-BUILDER DECLARATION
uy I hereby affirm that 1 am exempt from the Contrecmr's License Low for the
t?G following rentor (Section 7031.5.Business and
oo,damns Cale Any cry or county
_ which retia rcs n perm t t c t t lar,improve,demolish,fie a sig any stccmre
O
3 ..pit rot c al q pr inions of forthe Cohpermumicense aw(ned Cepter9
thatn -eapotassiumtdtn)r_provisions of icalP Law ods) Sq.-Ft Floor-Area M i., 9 ., $101OYouation
(co ncmg with Sxti n7000) flliviswnJof the Business and Pm(c inns Code) 1.yt.° byj (".�M A41 is"l lts,.v1E.1A 1«J. f
or that he is excmpi domfcm'and the basis for the alleged airmairn.Any violation
--of Seaman 7031.5 by any oWticmit for a pcmut subjects the applicant to a civil penalty
of but more than rive hundred dol'am($500). 3574PA Ngml6Y0 "`I'' �'�� Occupancy Type
Ell,as owner ofthe progeny,(,troy employees with wages as their sale compensation,
-will do the wnrk�and line'structure'Is not intended or ofead.l.,xie'(Sec.7041, 101 - FOUNDAT "'�i]'l r
k1houneii'and Professions Citic:The Contmnurs License Lew does not apply man wired Inspections
owner of Portnoy Who builds or improves Hereon,and who dans such work himself 102 - PIERS
j
or through his awn employees.provided that such impcvemcros are not inanded or _
completion,
erect fon sale.If,however,the building or improvement n sold within one yeai of - R... i,,�. p;t; ;O
e prove for the owner-builder will lint the hNcn of proving that he did not build or
improve for purymx of anla). 104 - REBAR '
_ .. _ 105 -----ANCHOR--BOUTS __ .._._ _
co 1 weer of the propc.7 int axil a sly t acting with lice,:)Th Cat omd n t 1 t
- Licenact a project fs 7to a ownerBusiness and propProerty
who
Crdc l The vemmctai s 106 - SEWER & WATER
License Law does not apply man owner of,erony who bulbs a d.Improves; the
_ond.whmar'sLmcts for s ..hprojects withacontm.i. bccnsed.pursuani.m the PLUMBING-202------UNDERF-LOOR-- -
s 01 ma a..,,i nda , _ 4 RANI CAL
'- ❑lam exemptnmders "` "' ''; ' '":e&PCrnrtnisreaaon 203 UNDERFLOORI'MEC
204 - UNDERFLOOR FRAME
WORKER'SCOMPENSAT1ONDECIeRATION 205 - UNDERFLOOR INSULATION
'. Iherebranirmunder penayrgfariJrratieofthemnowingdecmmdane:-- 301 - ROUGH PLUMBING
° I b:ve Edd ildir aintaio.'Cerium of Content to self-insure for Worker's 302 - TUB & OR SHOWER
at Compensation.as provided for-by Section 37M of the Labor Crate, for the
'perm ma.of he work forwnicntni..permitisis....d.. ., 303 - ROUGH MECHANICAL
°IMvc and`will mvti wa'keP:Compe mdo I{amoc,-naretiad 6r Strident 304 - ROUGH ELECTRICAL
opo ormalanor Code,for the performance of the work for which this permit is 305 - FRAME
Issued.MY Workers YCompen yuan Insumnc cam d Policy number am:. 3 0 6 i--HO r....
ss andr.
ca";.... l't f rv1rS' { ! (Pal cY No ..rr\A > F'
YI iCERTIFlCATION OF EXEMPT FROM,WORKERS'{' f 010 ) 307 P4.1AINSULATI'ON.s{ .a. ,
COMPENSATION INSURANCE ax♦ ` 3"OS 'hSHEETROCK"'-_
"'r i(Ths.carom neN nutMnimpldcd rf the pennn is for one hunJrcd dollars 309 '-I' EXTERIOR LATH '• '' 1)11. 1 f `
(S1011)mless)
I c nifY that in the pert rma of the to
become
ch a pato th waned 1 t li, ;, i,•l , .,•j
'
,hall at employ any fiction m any mai t so as ns hecom S hj,ct.�o they Workers 311 - SCRATCH COAT CompensationLaws atC Itmii Dmc "I -
.'Applicant ._... _ .- __... .. ..
- - 313 ._.-.__ROOF ..-._...._ ..
NOTICE TO APPLICANT:If.after making this Cerificate of Exemption,you should 501 - FINAL ELECTRICAli''ENERGY -
become subject t the WorkersCompensation ptov- sbr theLatter Code you must
cc hanhavim a.m,ply with inchjrot a,or thispmvi,shallbedomiedmocked, _502 - FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY - - 503 - FINAL MECHANICAL• ENERGY-'
Ihmby'aRirm that there is a construction leafing agency forte perfgmance 504 - FINAL BUILDING ENERGYI ' '`' "I
'of thework for which thispermit ued(S 309] O .C.)_
fender Na --- - - t
z NAL ELECTRICAL
Lend Adtl
v�0information50 - GAS TEST
,lineally That 1 h d this application and ate that the bo is
Lsa [� cnrren I agree a comply with all city and my ordinancesand state laws relating 5 7 - INAL PLUMBING
O"ptobcldmgconstmnion,andherebyauWhzinrepresenmtivesmfthiscitytoenterupon 5 8 - INAL C ICAL
�,,, (y the h e tnc t d p pe toy f r inspersion,arra _.
E,,..A. two) g t rot mnify and keep harml. the Ciry o(C pemn'o eganr 5 - INAL
'p3
liabilities.ludg eta costs rid parse h ch y n any y e against said
V
City n c asequence of the gam ng of th ermu 51 O
APPLICANT UNDERS IANUS AND W ILC COM1iLY WITHIALL NON-POINT
_ M)1JRCE REGULAnorvS..,*a'- • e •!��. +: Issued�$ _ Date
Sigrommof ApplicanniCantrepors:, t ;.:" -a'.,i,'Dam Re-TOOTS
1 t HAZARDOUS MATERIALS DISCLOSURE .'
:Xlfha applicm mfiction building eacupsam anion or handle harardous material Type-of.ROof. --- - - — -.
z d rived by the Cupertino Municipal Cade Chapter 9.12,and the Health and Safety
CodeSection 25S3 (a1\II °N \� -;{r11 ,it al w .14. l l�`: { i�(.
°Y" "r ATI roofs shall.be inspected.prior.,to any_roofing.material.being installed..
Will the applicantr future building acepeat oa equipment or devices,which If a roof is instalt&wittiout first obtainingan inspection, I'a Tee t0 remove
P g
erotica aray Bay ,all newmaterialsfor inspection. Applicant understands and will corn ly�with
contaminants as d fined b the B l
District?
i ❑ria °ry all non-rami Source regulations a;.,;: :11 P;
1 ha a readghe haea dove riaienxls q ¢menu undo Chapterb.95'af the
'Cahfomia Health&Safety Crile.Sections 3505.'_5533 end 25534 1 undersmrd ohm
if the pxomofhic'msnot cutremlyhave at,bemt itis myi,mn,c ibiliry iu notify,the
l acupont,of the regnirnmmais which miiv M met prim m issuunae nfn no man,of �• '
I' yS Occnpanar.�.'l g
Signature of_Applicant --_Date,- .,-
Owner orapth niciiagent , , Dole All roof coverings to be Class `B"or'better',
OFFICE --- __. .__ .. .. - __ ._..._