08050097 CITY OF CUPERTINO `""�
BUILDING DIVISION PERMIT 9CONLRACTOR,INFQRMA T`1
Bu11,91T�G�,S"N6GRANDE PL TBD — TO BE DETERMINED 08050097
7AW1cHITECTrENGIbnEER:
EWS NAME: PERMn'ISSUE DATE
RAJANI BALARAM 06/02/2008
NE SANITARY NO. CONTROL NO.
BUILDING PERMIT INFOBLDG MECH
XLICENSED CONTRACTOR'S DECLARATIONIOb De5Cr1 tion
i hereby affirm dont 1 am licensed under pmvisioru of Chapter 9(commixing pSection 70W)of0ivadoa3ofthe Business And Protrusions Code.And myIke.I. REMODEL-MASTERBED/BATH UPSTAIRS, DOWNSTAIRS
Zi in Licenm`Casand`ff`N Lk.. BEDRM-ADD 2 BATHROOMS. STRUCTURAL CHANGE
t„ Dao: Contractor
e ARCHITECTS DECLARATION
y 1 understand my plana shall be used as public record
76ddd
C Licensed Professional
y3 OWNER-BUILDER DECLARATION
� I hereby a�Rrm that 1 am eacmpt from rhe Convenors License Law for the
p O following reason.(Section 703 L5,BusiKss and Profisdom Cade:Any city or County
<.'� which requires a permit to con timer.after.improve,dcamulah,or mpai,any suuctum
till prior to its issuance.also,quirce the applicant for such Permit w Bk a signed statement
ESO that he is licensedparauantwNeprovisionsofthoContrctor'sUccmic aw(chapter9 Sq.Ft. Floor Area Valuation
til-$ (eommeneingwith Section 7MMofDivision 3ofOcBusinessandPrefessinnsCeMe)of $55000
5.- that he u exempt therefrom and the basis fm the alleged exemption.Any vlolatun of
Secure 7031.5 by any applicant for a permit subjects the applicant 10 a Civil penalty ofNumber O
sea mem than five hundred donate 15500). 3 6 218 018 .tS� Occupancy P Y T ype
1.as owner of the property,or my employers with wages As their Aide eompematon.
win W roewort.and the sm,tum u not intended oroffesed for Aide(Sec.70th.Rusiricv Required Inspections
and PMICAAb m Code:The Convertors Lime Law does ree nst apply to an Mamor or Q p
property who Wild m impose.;rhemen,and who does such were himselfor through his
Own employees,provided Nn such improvements are not intended proffered for We.ff,
however.the building in improvement is sold within one year of completion,the owner-
builder will haw On WNen of proving Nat he did not Wild or improve for purpose of
I,As owner of the property am euludvely contracting with licensed Co macturs to
Construct the project(Sere.7014.Business and Rafemlons Cod:)The CCovanoea U.
Corse law Casa not apply in an owner of property who Wilds or impasses drreon,and,
who contracts for such Projects with a convacmrts)licensed peasuant,the:Comanors
Lied Law.
❑1 am memyt under Sec w
B A P C for this on
tuner , /?n✓'r AA Date C
WORKER'S COMPENSATION DECLARATION
1 bemby affirm under peaty o(prjury arc of the following deelaratiom:
i have and will i for by
Section
37M ofContent r Coale.I. for eff.. Campm-
sstion,r pnvidW for by Section 3]00 of the labor Code,for rW prfo,mance of Vu
wart for which this permit is issued. '
1 ban and aril maintain Workers Compematlon Insurance,as required by Section
37W of the Labor Code,for the performance of the work for which this permit is Issued. '
My Workers Compensation tisumnce carrier and Policy number am:
Cartier. Policy No.:
CERDFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu union nu d not N completed rate permit is fmonc hund,ddonan(SIM)
or less.)
I corufv that in the Performance of the work for which this Permit is Wood.I shall not
employ any person in any manner,nlybcmm u4jc tetho Worken'Compensation
Iawsof Calor *to. U i
Applicanr sC J a :-_iL1
NOTICE T PI ICA W.IL aflor making this Ccnlfhcate of Esemption.you should
become subject b the Wor s Componat in provisions of the Labor Code,you mus
.J z forthwith Comply with such poviddm ser this permit Nall be themed rewkcd.
Z 0) CONSI'RUCr10N LENDING AGENCY
[-� I hereby afnrm that tare u a convection lending agency for the performance of
C the work for which this permit is issued(Sec.3097,Civ.C.) '
W Q lectin Name
z Lemke.Add.
U O 1 cemify Nat 1 have,cad dna Appliwion and son,don,the show info,mauw u
L,,,F correct.l agree W comply with all city and county on inanees and au,laws relating,
-0U Wilding Nwuction,and hereby audurim rep.nrsam ofNk city in color upon the
Fabove-mentioned Property for impaction purposes.
(We)agree to save.indemnify and keep harmless the City of Cupertino!punt
Z liabilities,aaic.o thens. mersts ,of this which mryin any way ucmc against aid City
U'� A PLICA 'T of circ granting of this pe WILL
� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
50 E RE "T_IONS�
6IL I0 Re-roofs
slgnuurt of ApplicandConuertor .,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof ltd
Will to applieant or forum Wilding occupantatme or handle hanrdow material
as defined by to Cupertino Municipal Cade,Chapter 9.13,and the Health and Safety
«lo,oYe nion 3ss3z(,)T GyNn All roofs shall be inspected prior to any roofing material being installed.
Will thea hent or future Wilding Occupant n, If a roof is installed without first obtainingan inspection,I agree to remove
Applicant geWvipr Qu ser devices which P
Il hvallom air Cmumimn�ts/ss defined by the Bay Area Air Quality Management all new materials for inspection.
❑Yea allc
1hewmadthehua cwsma„lapsmquimmenuunder Chaprer6.95ofthe Califon
nu HUI"SefctyCode.Suctions 25505.25533 and 25534.1 undcrswd thatifuse Wilding '
does not currently has•,nano that it is my responsibility,notify use Occupant of the
mqY rats Wh Corel W m t pinrb iyUNCt of a CCfllrwalo of DLNpaM.^f.
Signature of Applicant Date
Z
Motor or auOorb<d agent f pme I All roof coverings to be Class'%g.”or better