05100016 ;71495
TY OF CUPERTINO * '� -a-, v •�. x`a^n '4".'e a5s';��y..+F -'^
BUILDING DIVISION PERMIT CiONTRACTC)R INFORMATION %
g.,.,:. r "a„ ,r-x, aY,5r T '7bxw.'bk�r:•
LDING ADDRESS: CALIFORNIA CONCRETE CONCE AFINITND.05100016
PR 1FERMITISSUEDATE
ER'S NAME:
SRIVIDHYA GOPALAN 1405 GABLE
NE: SANITARY NO. CONTROL NO.
(209) 321-9592
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 I�
3 o 6 LICENSED CONTRACTOR'S DECLARATION
rd I hemby affirm that 1 am licensed under previsions of Chapter 9(commencing Job Description
with SeNon 1")of Division 3 ofthe Business me Professions Code.are my ties=is NNALEU
n in full fora and ertett DEMO (E) POOL T
j M a Dan Clan Contractor OCT -,r900[
S ARCHITECTS DECLARATION C d
1 underwnd my p Ws still W exact as public records
p 4 Licensed Pmfesaional ("("("Iflflf
OWNER-BUILDERexemptDE Ce Contractors
ON �U0 ,
sZs� I hereby.(Erns on I em exempt from the Canon t Co License Law co tits �j
`o o which re mason. emit 170313, t,Business and Improve,
du oli Code:My city s county
5$� which requires;a Permit m construct,alar.vnPmw,demolish,or repair anY structure 4 7 00
prior In its lasuanec.alsu nequira the applicant fortuch permit to file a signed statement
that he is licensed Purolator to Om pmvisioosof the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
t— (commencing with Section 70(10)of Division 3 of the Business and Professions Code)Or
33$
that les Is exempt Nemfmm and Ne Writ for do allc{cd aempUw.My violation of
Section 7031.5 by sny applicant for a permit subjects the applicant to a civil penally of r Occupancy Type
nut mom than fin hundred dollars($500).
❑1,uownuofthaproWay.ormycmploycawiNmn utheirmi mmpenution,
will do the wort.and lhuauctuu bnmimended oroRered forsale(Sec.7044,Business Required Inspections
and Poor..1.Come The Commente,License law dos rot apply m e an M.of q P
property who builds or i mprovra thereon,and who does such work h imself or through his
own employes,previded that such Improvements she not Intended oroRered forsale.if,
however,the building or Improvement Is mid within one you of completion.the Owner-
builder
wig have the burden of proving that he did ant build Or improve for purpose of
sale.),
E26.as owner of the property,am exclusively continuing with licensed ennuactons m
construct the pmjca(Sec.70",Baines and Profession,Cade:)The Comrsctor'a L4
cove law does naupply to an owner of property who builds or Improves Names.and,
who contras for such project with a eantrmtm(s)Ilcensedpuraunt to the Contractor's
License law.
❑I am exempt under See. B 6:P C( this recon
Wk
r'0 0
Owner Dau
WORKER'S COMPENS ORATION
I hereby elitm under penalty of perjury one of the following declarations:
1 hew ,and will maintain a Camficale ofComm�l to self-insum for Worker'sCompen-
atiun.u provided for by Section 3700 of the Lobos Code,for the per(mmame of the
were for which this prrmil is issued.
❑1 haw and will maintain Worker's Compensation limestone.u required by Section
3700 of the labor Code,for the Performance of the work for which this permit is Issued.
My Worker's Compensation Insurance carrier and Policy number art:
Carver. Policy NO:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This stolon toed not hecompleu l if the permit is fmonc hundred dollar($100)
or leu.)
1 certify that to the pnimmence or the work for which this Permit Is issued,I"I I not
employ any person in any manner an m to became subject to the Worker'Compensation
Laws a(Calif'�ipvp/tI
Applicant �fCC�IdYI�lTNKYA, 1 Q
NOTICE TO APPLICANT:If,after making this Cmdriau of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Codc,you mass
0z foMwith comply with such provisions or Nit permit shall be deemed revoked.
z y CONSTRUCTION LENDING AGENCY
(~ Ihemby affirm Wt then is a connuctimt lending agency fm the perfurmmme of
C
the work for which this permit it issued(Sec.3097,Civ.C.) .
W� 0 Lender's Name
z Lender's Mdmss
U p 1 certify that 1 haw rad Ws application and sum Nal the W.information Is
W mrnek 1 ages to comply with all city and county mcirumes ad sou leve missing m
Q building construction,ad hemby authority mpmmnuttva of this city matour upon the
above-mentiomd property for inspection purposes.
(We)agree m ave,indemnify and keep humlea the City of Ceperti al ayaiat �U'— of rd r�
fA Itabilidesjdgmenls.cuts and expenses which may in my way mane against said City
U 7 In consequence of the gating of the permil.
r7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REG xLATION .
Ili >1(�tA` f.0�4 OS Re-roofs
Signuum fAppliMVCanumtor Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant atom or handle huardous material
u dcOmd by the Cupe)rdm Municipal Code,Chapter 9.134 and the Health and Safety
otic, Oyu 32
�/ All roofs shall be inspected prior to any roofing material being installed.
❑Yu Bd*+o
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It ha'ardnus air conumians u defined by the Bq Area Air Quality Mm tgemem all new materials for inspection.
D,;lekt7
❑Ya Ew-�
Ill ave mad the huardmta maurialsmquire ncras underchsp er 6.95 of the Califor.
ria Hcolth GSafetyCak,Secdou35505,35533adi5534.1und awdthuifthe building
docs our cumendy haw s we.%the it u my maponsihility m notify tic oceuPant of du
requirements which mount Gem 'orwiauarec ofa Ccrefeau or pony. Signature of Applicant Date
Uv. > �9,� ID fps All roof coverings to be Class"Bo or better
Owner tar wthorized a em Tac
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CI Of Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
O.SpEc7 A 7�
oCUPCRTiN,1, qS6/� 0S`/40o1 e
OWNER'S NAME: PHONE # $/D-S79-fg-�
GENERAL CONTRACTOR: c?-0 FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
He
Owner/Contractor Signature Date
CITY OF CUPERTINO
DEMO Of
CUPEkTINO PERMIT APPLICATION FORM
APN#7 41 / S� 6 Date:
Building Address: 1'kojpc� /
7�9r 6!'�, C�vF,e
Owner's Name: (1Phone#: .
J og-�D�sss X109�g
Contractor: License#:
UI CTo,e S/ LVA
Contact: S'p(J � WA //ter n y/ ,yJ Phone#:
Applicant/Contractor:
Building Permit Info:
Bldg Elec . Plumb ✓ Mech
Job Description: - �rnDLI S PcbL 11✓ �RON7 y�
Residential: ✓ Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation: 4 �o D 077
Type of Construction: Occupancy Group:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Pemiit Fees BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
BSEISMICRE Seismic Residential BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BUSLIC Business License BUILIDNG