08020150 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 3aCO1�RACTQR�IN�'ORMATIO
BUILDING OGRESS: PERMIT NO.
10370 PALO VISTA RD TBD – TO BE DETERMINED 08020150
NEWS NAME: PERMIT ISSUE DATE
GERARD PALLIPURAM 03/11/2008
PHONE: SANITARY NO. CONTROL NO.
ARCH=IFNGINEBR: BUILDING PERMIT INFO
BLDG EIECr PLUMB MECH
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woo LICENSED CONTRACTORS DECLARATION Job Description
I larch,maim Nu I am licensed under provision of Chapter 9(commencing
nSj of with Section 7010)of Division 3 ofdw Business and ProWaluru Code.mal my license is ADD 1 STORY MSTR SUITE(410SQ) , RMDL HALLWAY
mSin full force antl effect.
Z_ Lt....Clan Lia.L
Dau Connector
liqARCHITECTS DECLARATION
1 underaured my plans"I k used u public record,
U
g W Licensed Protean ..I
OWNER-BUILDER DECLARATION
S 1 bercny atitu that I am exempt room Ne Canumewes Licenw Law for the
0 o following moan.(Section 7031.5.Business and Pmwuiom Code:Any city or county
I I which requires a permit to cmanuc.alter,Improve,demolish,or mpair my suuctwe
Ztn prior w its luuance.alu requires m,'PPlieanl formth permit at Ole+signed statement
�o twhei,lien,mpnrtttanitoNa"vimomorNeconmweiucc uw(enaprw9 Sq.Ft.Floor Area Valuation
5 (crmatedngwithSection7000)ofDivision3ofNeBusinessandProfusion.Code)or $50000
Nat he Is exempt Nertrrom and w bots for the alleged eumpnon.Any violation of
Seaton 7031.5 by any applicant for a permit subjects Na applicant to a civil penalty of Number Occupancy Type
ant mom Ilan five hundred dollars(55DD). 35702 0 51 40
I,a awmr of Ne propmy.w my mployen with vnges a Nenmk cmnMMOM.
will W the wod;sod a To Cma re mlinunded Law does
to an,B neer of
and Property
who
carie:mpr wsmecwf.Licenseand
Law dew nal apply to rt awns of Required Inspections
property who builds or rmptovea Nermn,sod who rias ouch work himself ed through his
Ownhow a however.
pan
ailding ed that wmech nt is vements am not earof tl craffeopted n.farsam.do own If. '
however.Ne have
the
or improvement Is old within oro year of mpro a for the owner-
otltler .will have W Orden of roving Wt k did Out build w improve for purpose of
uleJ.
1.u owrcr of the propm
property,me exclusively cemAng wide OceW contr
oactors to
trues time project(Sec.7044.Bust.and Professions Code)The Contracts'.U.
mow Law does not appy to an owner of property who builds or Improves tkman,and
whacontracts for such projects MN•mnu+m r(s)licensed pursuant to that Communes
L Linn Law.
❑tem esemptunderSee — .B&PC Nis maser.
net Date
WORKER' NSAnON DECLARATION
I hereby+fTim under al"of Perjury oro ortiu fallowing dectmand nc
I]1haveaMwillmwaCadOesuo( o wactf-Wererw Wwkrs Com
dan.u ovidd roby SmtinJ7000(Ule LAbor Ca .(w W peforce offt
wat fw.wnieh this remit ts inewd
❑1 have wad will maintain Work'.Compensation In.uranw,as required by Samoa
3700 of dta labor Code.for the perrmman"ardm work Tor which Ni.permit It isawd.
My WerkeM1 Compo umimt In..carrier rand Policy number art:
Carder. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TTisswion reed ant k completed if tit permit is foram handed doled(SIM)
or leu)
1 cwtiry Not in Ne performance f to rank for which this remit tswand,l siert ant
Liessoanypaommmn any mann s as5o becmmesubj ITeWor, Compewtlan
I.+wsar Califamia.Dau ' •!vew.,U�
Applicant
NOTICE T'0 APPLICANT:Ir,�e aWing Nu CenmOca c of Exemption,you Amid
become Subject w tiw Worker' repewtion Provisions ser the Lakr Code,you mute
z foMwith comply with smh alwnw this permit shall Ise deemed.1cel.
',Z,'� CONSTRUCTION LENDING AGENCY
[-+ IkmhYarrimand Nero ts•onmruction lending agem,for Na perfwmarce of
C> Ne work for which this penin In luded(Sm.3097,Civ.C.)
QLanders Name ,
Z) z Lenders Adams
U Q I comity that I have reed Ni,applkadm and sum Nu the abow infatuation is
Iy !". con"L I a,,"w comply wed all city and count'wtlinameuM ante laws minding to
C rV" building construction,tend kmby auNodu reprtunutivu of this city to enter upon Ox
4n move-mcon onW property for inspection purpoxs.
LL (We)agree m arc,indemnify and keep hemuss the City of Cupertino agaiut
n,m y Ilabilides.judgments,cans and espcwu which may in my way accrm agsiot said Cly
V z in consequence of the granting of this Fermi.
APPLICANT UNDERSTANDS AND VPLL COMPLY WITH ALL NON-POINT Issued by:91ta� Date
SOURCEREGULATIONS. ✓C(/
Re-roofs !—
SignuumarAppliwnnCo"ame'" I Dim
HAZARDOUS MA DISCLOSURE Type of Roof
Will theapplicantor rusam bullet wcupe tuaro or handle anomalous matedsi
as dented by the Cupenim Munidpal Calc.Chapmr 9.12,and Ne Health and Safety
.Seadon 25532(a)7
DYes Na All roofs shall be inspected prior to any roofing material being installed.
- [2
Will time appiwant or future sus
building occupant e equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit huallous air commitments u defend by the Bay Acta Air Quality Management all new materials for inspection.
Disuict7
[:3 yes odea
I have read Ile Ince mmedW rtimnancnts under Clemurb.95 of the Cattle,.
rah HcoW k Safety Cade.Sccdons 25505,25533 and 25534.1 understood der ifdu building
does not cumntiy have a tenant.Nu it u my mammedblliry b entry do occupant of the
myulrtntenu which mot be atpi rw muemeoraccmnca of pacer. Signature of Applicant Date
I kg
Ownu w mNomed+gens/ I f DaAuM All roof coverings to be Class'#"or better
'