03120059 CITY OF CUPERTINO �+*° =«ro. 3d7 -� '"��"�"z �`"�'"` ' '"'
Bu1LDlrvc DIVISION - PERMIT 00INF'd�2MAT1yON
BUILDING ADDRESS: PERMIT NO03120059 312 O(]S 9
an T)p
OV(NER'S NAME: PERMIT ISSUE DATE
RASAGOPAL
E: SANITARY ift3l.NO.
ARCNTfELT/ENOINEE0.: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 l�
"tax LICENSED CONTRACRWS DECLARATION Job Description
1 hanky sfl7rm Nat I am licensed umkr provisions of Chapter 9(commencing p
k< with Section701k1)a(Divided 3 of We Bagnm and Professimu Code.end my[is..is
infull force Cluand ercem. KITCHEN REMODEL/WINDOWS UPGRADE
Z�3 Dow Chas Cee M -
Date Cerement'
ARCHITECTS DECLARATION
I uMcrwnd my plans shall he used as public rworN
U
3 C Lkenwd Potential anal
OWNER-BUILDER ER DECLARATION
iq 1 masa nffum I am exempt from We COnwal Co :Any c Law for the
0 0
which
following reason,Permit
(Section 763 L5.Business and Pe,d aimil Cmle:Any city or county
$� which ren Issu a e.aim m wwwct alar.Improv,do permit
t car mpWr any atructum
prior kslissuance,ricomquira pWe mepplkso for suchpermluo Glaasigned aukmem
F�F�Si (cmdoms ngwiitpurction7 )of Division
of of Business
add PrefLaw(Chapter Cow)OF Sq. Ft.Floor Area Valu [ion
C a'S (wrens aexe pttSatioon and of hems
o(s We
Bedinu and Pmfeviomudonof
Nat he u exempt Wertfrom and We buu fm the alleged esempliw.Any violation of
Section 7031,5 by any applicant fm a permit subjects Be applicant o a civil penahy Of 3 GVW' c*O Occupancy Type
not mom than fin hundred dollars($5601.
I,in owner of We property,amy employees with wages on Weir solo compensation,
will do the workand Waslmckm isnotinm doro@edforsale(Sw.704a,Bu6nm
and Professions Cale,-The Conueckr's Lieeme law does not apply k m owner Of Required Inspections
propertywhO buildsorlmprovas Wereon.andwhodoesa xAt work hinewf ortNough his
Own employees,provided then such improvemesu are not intended or offered(orsale If,
however,We building or improvement is sold within nae you of awnpieuon.We owner.
Wilder will have the burden of proving Nil he did not build ar Improve for purywe of
Nrr,
construct owner dj the property,.B exclusively mid contracting with liaised conlrmml k
aseLaWe projm(Sec.n an wusinm roil property
who
Cade:)The Co Warner.Li- 4O V
who law dors not ehPIr k an owner or property who builds or improve Comm.and oA
whedge Lacu for each Projects;with aconusckr(s)licensed purwamkNe CantrstoYs lAD3�® `F
Cleave law.
❑1 and exempt under Sec ,B&P C far this sson
weer Date /2'
WORKER'S COMPENSATE lARATION
1 hemby affirm under pciWly of perjury arc of the following dealaauone
I have ad will mMouth a Cesufnak of Consent k self-Wom,for WorkersCompa-
sation,is provided fw by Section 3700 or the Labor Cade,for the performanm of Be
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Ensurma,as required by Section
3700 of We Labor Code,for We performance of We work for which this permit is issued.
My Warker's Compensation Ivunnw carrier and Policy number art:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissation wed nolhccarepleted lfthe permit is future hundred dollars(5101)
or less.)
1 certify that in Ne Knrormanw of We work for which this permit Is issued,I shall not
employ any pence in my manwr an in k bawmo subjest BE the Workers'Compass lon
Laws Of Ci iforen,Data
Applicant
NOTICE TO APPLICANT:If,after making one Cerifewc of Exemption,you should
become subject in the Worker's Compensation provisions or We labor Code,you must
.JZ forthwith comply with such provisions or this permit shall be deemed revoked.
ZCONSTRUCTION LENDING AGENCY
O
IMmby gfirse us,Wert u•anctmctom lending agency,tar the pafturana of
C > We work rut which this permit Is isswd(See.3097.Civ.C.)
Q Lendce.Name
cL
D Z Lenders Add.
U O 1 certify Was I have lead this apptlauon and auk Wat We above information U
a2 E correct.1 agree to comply with all city and county Ordinances and state lawn relating k
C) building concoction,and hereby audmrim representatives of this city to toter upon the
ITT shove-mentioned pmpeny for impaction purposes
d (We)agree k save,indemnify and keep an rmlm the City of Cupertino against
rn Ilabilida.judgmcata,emu and expenses which may In my way accme aguvt said City /
V.Zin r APPLICONANDwung of WILLANTUNDEof We RSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date 11/
RCE REGULATED
'2-/)1
/173
ro Re-roofs
Signature ofAPplic HAZA amwWr DOUS MATERIALS DISCLOSURE Data Type of Roof
Will the sppliant or run=Wilding occupant am or handle haallous material
as defined by WC Cupertino Municipal Cade,Chapter 9.12,and We Health and Safety
add.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes gO
Will We applicant or forum building Occupant tau equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it harardnus air contaminants in defined by We Bay Ama Air Quality Management all new materials for inspection.
District? _�!
❑Yes CA.
I have maJ We hvardws makriaisrtquiremcnu under Chapkr6.95 e(Wc Califon
null aldt&Safely Cad,Sccuov 25565.25533 and 25534.1 understand Wmifthe building
docs not tonearly how s karat the it is my remana bility k nuul'y lye aeupmt of the
kqui aixwhichmugbe9�etpriorwissuanceoraCattlle o(kEapannr. Signature of Applicant Date
C`T '/VL r aAl�4'Vr2'., 11/71 0�?
Owae ersatherivedas m- • Dole roof coverings to be Class"B"or better