00090068 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS:
' ADDRESS: PERMIT NO,
OWNERSNAM12I¢14 APPLICATION S
-PHONIAMAKSHI SANITARY NO.K
p K Z ARCIII I'IiC'I ENGINIHIR: — BUILDING PERMIT INFO
OOt�. BLDG ELECT PLUMB MECH
j
LICENSED CONTRAC'TOR'SDECLARATION Job Description
p S= 1 hcrcby alarm that 1 am licensed under..... kar,or Cf,i o r 9lcmnmencing
v:I-w with Section 71X10)of Division 3 of,he(bushels and'Imo e Card nq lieeave
Syg-'j ciot'ullrnrccnnd,l I C
ae z¢ Licence Class
p_ � Lic.x_ .
5aH Det`—tet 10 RCIIITT,CI"SUICLARAT REF'IPE, WATER SERVICE
C n° 1 undcramW Inv prone shoo be.,ed us pante record,
2r i /
ureal d p hiccnttd Professional
m OWNER-BUILDER DIeCLARAI'ION
hereby offino that Iran exempt from the Conwna's License Law for the /
1- a following,emon.(Section 7031,5.Business and Pmfnsion,Calc Any city nr county
d o whit 'Inuit V 10norricl.ale, ir,o,c.de,nolikhro,pcTru,troy usucoure
a3_ pint t e '1, 4 ;tl 'ppbetl Ip It tlg I' tta ,
fntl 1 .ed l,t. n ms 0(n n. nn c t r L n La (ChpmrY Sq. Ft. Floor Area VMubation
(connvncng,c fleet 711110)of Division 3 of the Business and ProfmiorovCrile)
or the,he is exanp feelroo ood the hwie lin he ulleg¢I exmnpdno.Any vinla,ion
of Section Toe 1.5 by any applicant for a permit subjects the appheant m a civil penally APN Number Occupan
of not morn than five hundred ill($500).
❑1.us owner of the rynpcny,"'in,employees with wages as their.nlc comb.;nwtion.
will do the work.and the structure is not intended or offered Inc.ale(See.78W4. 36204 ,.:r
Boa nese and Profession Cale:"The Contractor.License Law docs not apply to an 1 ed Inspections
owner of prnpany who muds or In,pn, w.hercnu,nod who doa,vuen work hlni,,Il
of through his own anployee,.provided that such imprvvcownrs sere nor immrdcd or
offered for sur.If,however.the building or improvement is sold within one year of 106 — SEWER R WATER
nmOlelmo,frown,,hoilder will have the burden of pawing that he didm,t haddor 2Vi2 UNDERFLOOR PLUMBING
tpmve Tor pur,o v ofvale.). —
❑Ln owner of the pro,perry,uoexcluniicly contracting with licensed connector,ill 301 — ROUGH PLUMBING
m,r reel rhe pntjea(Sec 7044,Businoe and Prole,iou,Code,1 The Commemr'a
Liecow Lawdas nor apply ,,all owne,ol ,,pity who build,,,, uTa.,es lemon. 302- — TUB & OR SHOWER
and who conim,t,Tor reh project,with a connactom)firmed pursuant to f` — FINAL PLUMPING ENERGY
cotlnmcon,Liccn,a Law. 502
l am esempt nmkr Se,. ,B&P C dtr this n:uoo 506 — GAS TEST
°soar WORICER'SCOMPEN`SATIONDECLARATION 507 — FINAL PLUMBING
I hereby affim,under penalty of perjury one of the fallowing declarations. v
❑ I have and will n iourin a Ceniticatc of Couscn, m,elf-lowle for Wnvk,r'r
Compemmi,,n, as provide) Tor by Sect o„ }700 of the Labor Code. for be
pertirrmance of the work for which this permit is issued.
❑I have and will maintain Worker's G,iii encuion Insnrnncerm reynireJ by Section ,
370()of the labor Gale,fir the peifon,unen or the work for which This p.,it is
i.wed.M W'nrser's 1{rF1•x�`I thi nation loonance carrier and Policy
number are.
CunierlltlCATNOFIi\I.NPf10N�RO.\1 W()RKOS'Wil
COMPENSATION INSURANCE
(ili,section need nm M completed it the penult is for one hundred dollar
(5110)or Ic,1.1.
I eenify Nat in the performance of he work lin which this permit iv issued.I
shall net employ any person in any manner so as to became subject to the Workers'
Competnmhnl l.awv t,rcalir,,rnio.Dam
Applicant
NOTICE TO APPLICAUT:Il,alter making this Cenilicaln of Exemption,you should
hecnme subject w rhe Worker,Cnmp,nvation poviainn,of the Las"Code.You must
O O umhwith eony9y will ouch pmvi.amu or this peonit shall bedeclned r,vnked.
F W CONSTRUCTION LENDING AGENCY
Ra ; I wk nr mbifl that lu,them is a undmSec. lending agen,y for the performanec
� ol',hc work Ibr whish lis punit is issue)(Sec.31197,Clv.C.)
CLC Lender's Name
a Z (.ender',Adi
C.1 O 1 rectify that I have read this application and state that the mouse inlbmmtion iv
tr. F correct.I agree m comply with all city and county ordinances and state laws relating
O f,) mhui being conamcllo,n and hcrcby nuthorL.e representatives of city In enter upon -
fey rhe aM,ve.mentioned property lo,Inspection pm pore,.
F y (We)agree in save,indemnify and keep lrnnlevs the City or Colxnino ag.ins,
V) I'tab'ditics,judgments,costs and expenses which may in any way accrue against said
UZ City inammTic ncc of the grinning of T his ps, it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONH'OINr Issued by: Date
SOURCE REGULATIONS.
Signamm of Appllctm✓Conlnn'rtn Omc Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
W511 the applicanl or future building occupttn.woe or handle hazardous material Type of Roof
I,dciined by the Cupertino Municipal Code.Chupmr 1).12.rind fe HeaIll and Sday
Crile,Section 2553:(.)^.
[3,e, ko All roofs shall be inspected prior to any roofing material being installed.
Will the apprcalaortanmbuilding scrmnn,ow,eyuipm,mordevice%which If a roof is installed without first obtaining an inspection, I agree to remove
•mit hm mloa.s air a newco uinh as ill by the Bay Arca Air Quality Management
E,trier, all new materials for inspection. Applicant understands and will comply with
o Y,x all non-point source regulations.
1 have mad the hanrill material,requirements under Chapter 6.95 of the -
Callfomor,lleahn A Safety Code,Section,25505,255))and 25534,1 understand that
if rbc building docs not currently nave a mount,that it luny re"r000l lllry'.rail,the
ce ,n aft rcqu' m nts which must be tact prior m i.....nce nr a Cer ificme of
e'upmty. Signature of Applicant Date
ownermamhon:ed^gent Dale All All roof coverings to be Class `B'• or better
OFFICE