05080242 CITY OF CUPERTINO
BUILDING DIVISION PERMITCORACTUR IIVF,.ORMATIbN
BUILDING ADDRESS: OM BUILDERS, INC PERMIT NOO 5 080242
7510 RAINBOW r)R
OWNER'S NAME: PERMIT LSUB DATE
ANTANEYULU KROTHAPALLI 37053 CHERRY
E; SANITARY NO. CONTROL N0.
(510) 744-1085
ARCH=(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t� 0
3 o O LICENSED CONTRACTOR'S DECLARATION
u 1 nercby affirm that I am licensed under provision of Chapter 9(commencing .fob Description
n,t�`of with Sudan ln0)of Diviaien3of dre Buaiaasand Pro(esdom Code,and mylicemeis �'� Q ��®
in full force and effort DEMODean Clma Cnuuar H
9ARCHITECTS DECLARATION
3 y, LicaseduProd fessund t nal y Pines
.hail he used u public round, NOV r��.2UU5
50 OWNER-BUILDER DECLARATION L J
a
0 f I heathy.(Su a n 1 em exempt from the Contractors od Licence Lew for the
i p O following re&Son.(Scction lin L5,Business and Rofatlum Cod:My oily or county k
v1$� which acquires a permit m cnnumet.Blur.Impo n,dcmoluh,Or repair any suucm4 1 O�D re �a 0 0
Z��r print m its issuance.also requires the applicant forsuch permit fle..igned MutualF O tlutheisllamedpunuanttoftpmvlaiomoftheCantracar'sl"=Uw(ChIPur9 Sq.FL Floor Area Valuation
(commencingwiUt Satian700Eof Dis ion3ofthe Businmud Profaaiona Cnde)or
.. dont he is exempt therefrom and the basis for me alleged erempl n.My vioution of
Section 7031.5 by&try applicant for a permit subjects the applicant he a civil penalty of Occupancy Type
Act more than TOO,hundred datum(530)).
❑1.AS ormn of Ise pmpeny,ar my employes with warA as dub sole ammpenmdon,
will do the weak and dm swcmm u nm intended or offered for ASIA(Sec.7044,Busiws Rid Inspections
and pmdmlom Cade:Thm Required,Canuacmes Laos,Law dean mat apply an owner of
property,who builds AS improwdurmn.andwhodoessuch work himselfort rough his
awn employees,provided thatsuch improvements Meant Intended aro@red fornme.If. ,
however,the building or Improvement is Sold within ane year of impletion.the owner-
builder will have the burden of proving that he did not bald or Improve far purpose of
sale.), .
1,as Owner of the property.am exclusively conducting with Ilcensed contracmra m
komtmct the project(Sec.704x,Business and Profession Cade:)The ConuxmYs W-
ceme law docs not apply loan owner of propimy.wha Wilda or improves thereon,and,
who contracts for such projects with a commuter(s)licensed pursuant in Me Communes
License Law.
O l am exempt under Sea B&P C for this Mason
Owner Dau
lz
WOR COMPENSATIONDECLARATIOa�
1 hereby Llano under pc sadly of perjury ane of me following daivatoua:
❑I haw and will maintain aCerdfiateof Convent An self-insureforWakeraCempen-
Milan,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
❑1 ban and will maintain Wallace.Compensate.Imuranca.u required by Section
3700.[the labor Code.for the Perform Ance of the work fa which this permit is load.
My Workers Compensation Immounce cariersud Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
flbuaumm eecd.maccomplaed if IM permit is forme hundred dnllars($1011)
or[am)
1 unify,that in the performance of dates workfor which this permit is issued.I"t am
employ any person in my manner so 7;p 1gjefl to the Warken'Compensation
Laws of California.Data
vrf
Applicant OK
NOTICE TO APPLICANT.If,after making this Cenifcam of Exemption.you should
become subject in the Workces Compensation pmNsinn of me labor Cade,you most
.JO forthwith comply with such provisions or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
[-i I hereby ARM that there is a instruction lending agency for the performance of
IY> the work fa which this permit is Wood(Sec.3097.Civ.C.) '
MW A Lenders Name
z Lidos Addams
U Q 1 unify dot I have rad this application and rete mnt the show infoonatin Is
{7.F COMM 1 ogre to imply with ail city and county oNimncea and sou laws relating in
QU Wilding convection,and hereby authorim repreaenmiws otthis city to enter upon the
ahave-mentioned property for Inspection purpaes
�^ G (Wer)agree to sew.indemnify and keep harmless the City of Cupertino against
IZI liabilities,judgments.emu aM expenses which may In any way acme against said City
C.3 7 in consequence of the grating of this permit.
M1- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINI Issued by: Date
SOURCEREGULATI
_ IDQ a2 Re-roofs
Signature of ApplicantAContractor I Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or tuttm Wilding uccup&at store or lundu haardoua material
toefined by du Cupenloo Municipal Code,Chapter 9.13.and the Health and Safety
u.Suit..25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑YuNAWill the applicant or umm Wilding Occupant use equipment or devlaa which If a roof is installed without first obtaining an inspection,I agree to remove
haxa doan air conmminants as defend by the Bay Area Air Quality Management all new materials for inspection.
c17
❑Ya PIN.
1 haw mad the hartmouls materWs requirements under Chapter 695 afthe Califor.
Health&SafnyC&c,Satiate 25305.25533 nd 25334.(understand tut ifine Wilding
not currently how a unnt mat It is my responsibility to notify Be occupmt of the
oupdomenu which most Is and rml aamcc of&Cenifnte of,Occ p.ney. Signature of Applicant Date
Owner ser autnotsed egcnt //J ate All roof coverings to be Class"B"or better