00050195 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: —may
BUILDING 11W!8:1 PHAR LAP DR rERMrr rvo. ----�— t=
OWNERS WORTHY, RAN, KRISHNA APPLICA'r10N SUR I 50195
• PHONE SANITARY NO. R^
WO
O z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
pt— HITvG ELECT PLUMB MECH
Neral 1.I IJ 1=1 IJ
2
wm 7 LICENSED CONTRACrOR'g UIiC1.ARAl'ION Job Description
z0 y o1 hemby alfien That Inn,Eem,.ed un ll provisions orl]mpmr 9 aommenemg
tw wim SmIinn Y 41al0lof Uiv' nn 3400 Rnxinexeand Prufax+ions Code.and ma
y Lnse^
is in full force nodal
rr
tiz w licence Clmz Li,.p
C. Data Connncmr
B u. ARCHN Ecf'S DP,OLARATION
t u� 1 wulerwmW my plum shall he used ns public mn,Ns
cess MOVE WATERHEATER
Llccnad Professional
OWNER-BUILDER DECLARA'I ION
u� I hereby nolinn thin 1 xrn cxcn,pl from he Commctor'n Liecnx Law(,I,th<
t> fnllnwinmo
g rca.(Semon]0115,Business and Professions Code:Any city or county
E which regorms a factor to nmamd,alref,I.,.,c.dral ish,or afar any snunura
i3 prior tootsi.wanca,a)wmqulas the applicant tmr.wch paminn file axigred,boamem
mat he is hcenscd purwant It,the Nowt n,onbe conninorx l,icmm Law(Chapter Sq. Ft. Floor Area V• atfDn> �1
I.,mmencon,.,Th Section 1(11X)of Division 3 cf the Business and Pro(msions Colo) V
,r that he is exenrft ncnmfron,unit the basis for the alleged ewrnuion.Any violation
of Section 7031.5 by any applicant for a floor subjects the applicant to a civil lxnxlly
of not mom than live hunaad dollars 195100. APN Number Occupancy Type
01,as own<r..f me proNny.or any cmpbyce,with wage,ns that,vole cnmpancaliaa. 32639050. 00
will dt the work.Lind The worw ure i,nor intended or offered In,sale(Sec.7144.
faire„and Pmfe,xion,Cai F,Cartoon m,.,License"w does not afply ,,air Required Inspections
or of roperty Who builds or improves Thereon,and who does such work himwlt
or Through his own cmployces,provided mut wch iinprovemems arc not intended or
totaled 1'or sale.If,however.The building or imfravement is cold within one year of
imm,plcrir(11f the owncrfb'dc,r will havcme huNen of mvin,mal he did not Wild Lir 106 — SEWER R WATER
frosa purpraao
01.a,owns,ot hefroferty,at,exdtoi,Ty unrraenngwith licensed eordanor.n, 202 — UNDERFLOOR PLUMBING
]mxaua the Pmjecr(Sec.7141.Rusine,s and Professions Cod J'Me Convenor,
,manse law does not apply it)an owner of property who builds or improves lhareon. 301 — ROUGH PLUMBING
and who controls lot such projects with a contractor(.)licensed porsaam ro ma 302 — TUB R OR SHOWER
Ctoaraoid,Liemtse Low.
C l an,exompt ander,See. .B F P C faults reason 502 — FINAL PLUMBING ENERGY
owrrm Date
WORKER'S CO DaveA'IION DECLARATION 506 — GAS TEST
I will,upon wads,pTvalty of perjury one otlhc fallowiog deeln mane: 507 — FINAL PLUMBING
0 1 have and will mdntain a Certificate of Consent to self-in.wre for Worker's
Comp:n,anon, as provided for by Section 3700 in [lie Lubar Cole, far the
performance of rhe work for which this permit in issued.
01 have and will maintain Worker's CarrNmetion Insurance,as squired by Section
3700 of the labor CWi for the arlonnancc of the work far which this whorl is
sued My Workers Compensation Insurance carrier and policy number all
Currier: policy No.:
CI71O IFICATION OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(I his section need nor W nmrplcted if the pennit Is for one hundred dollars
191001 or Iem.)
1 certify that in the perfnm,anee of the work lit which Ihh permit i.,issued,I
shall not employ any person in any manner so as To hcnmm whjco or the Waders
Cnmpcnxation".,,it Culifarnin,Data
Applicant
Not WE To APPLICANT:IE afar making thk Cartifica,,of Eacmption,you should
hceome subject or the W..i Compenwlion pravi.in s of rhe Luhor Code,you must
Q 0 forthwith comply with wdt Nnvixlons or This,rrnit shall be Acenmd revoked.
z _
F ^ C(INSe.is.ION LENDING AGENCY -
ai I herby wITT.hich that them is o conal(See lending agency Tonle Nrlunnance
of ri work for which his permit is iswaJ(Sat.3197,Civ.C.)
z Lender's Name
� � I,anJcr'sAdJress
V 0 1 comfy that 1 have read this application and side that lire above intion ation i,
B. E.. correct 1.grata to vani with all city and",.:try ordinances and tune laws relating
Q C.) to Wilding sun.amclion.and hereby adhonLe representatives ofdds city I,enter ury,n
he aKill.rnentionad propany for inspectmn Wrfoscs.
(We).........ave.indemnify and keep formless the City of Capital ano,
Z liabilities.judgments,costs and expenses which may in any way lateral agdf.at said
U "L
City in consequence of the granting of this femw.
_ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: � Date
SOURCE REGULATIONS,
Y'
Signaureof ApplicaMCamreaor Ione Re-roofs
HAZARDOUS MAfER1A1.5 DISCLOSURE
Will the appuc:mt or future building«onfanl Loom tartaric ha.amams rmatedal Type of Roof
as defined by Ilia Cup,i ia, Municipal Calc,Chapter 9.12 and the Ileallh and Saba,
Cade,Section 25532(0)'
0 yes ON. All roofs shall be inspected prior to any rooting material being installed.
Wit l the applicant or l mare liuilding reeupearl use ctriplecat or devices which If a roof is installed without first obtaining an inspection, 1 agree to remove
miI hat o lou,air eonwnrinm
ns as defined by the Bay Arca Air Quality Managanem
o•iorml" oN all new materials for inspection. Applic:mt understands and will comply with
all non-point source regulations.
I have read Ilia hazardous materials requirements under Chapter 6,95 of the
Cul hernia Ileath h Safety Code,Scaions 25505,25533 and 25534.1 understand that
If the building Ares not currently have a tenant,that it is my respansi lility To nosily the
culont of the mrrvimmants which moa W sun prior I,i.wance,of a Ccnif in,of
Occapamcy' Signature of Applicant Date
Owner oramhoriaedagent Doe All roof coverings to be Class "B" or better
OFFICE