01120073 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20192 RODRIGUES AV 01120073
OWNER'S NAME APPLICATION SU DATE
SHEKAR PASUMARTHI 12/ 182001
% ION, SANITARY NO. CONTROL NO.
u O p ARCHITECffENGINEER: BUILDING PERMIT INFO
w- BLDG ELECT PLUMB MECH
<�G u L ) u
pan
LICENSED CONTRACTOR'S provisions
haps
.�`_'z I bomb a)of thin 1 30f,hc B ander °Tena ler.and in,lenens P Job Description
iz=� r nm.tismm P 8 REPIPE/PLUMBING
,�C; with Section]IHI it of Division 3 of the Rosiness and Pmressiom Cole,and my license
s I_ is ce full force and•Ire
fit Di 1, Cas Lic.a LISZ_Z/�a--Jyy------
1 3 a r nwe � S DECLARATION la Yr}�(�y2afy,_
u,O v A CHITECme DECLARATION' {`
1 undersm m plans Sha uttd as pante rtrnrds
16 0- Licensed P
sr
ce
-NUILDER DECLARATION
tial^_ 1 here fimt that 1 am exempt from IM1e Contractor License Law for the
following reason.(Section 7031.5,Business and Parfessions Code:Any city or county $3900
ce F C which tits rc>a perm t re construct,alkr,'rep demolish . y,Vu°ort
n 3 z pce c: ri.1i t c I q 'te rhe pylic t r bry a fl 'gn J:t t mem -- - - - - - - - - - - -- -- -- ---
Ilm he I-tt «d p n a n the props ons or the C Imct n Llcenx W on,Covr 9 sT y Valuation
(con ,cM pg all Sccl 71wo1 of Di,ix 0 3 nn he m.rme. tie Prnre,a,mna Cndel t 'FR. � ) 3,§tB 2 bl4)9t;,. TER{:'t(:#t If f: ,.
or that he is exempt dinefmm and the basin for the aIligW eaemptbn.Any violation
of Section 7031.5 by any applicvm for a Permit subjects the applicant to a civil penalty'
of cut more than fix c huneied dollars S500). 202NPN N94H4138RFLOOR PUMBING Occupancy Type
°1,as owner of the property.or my employees with wages as their sole compensation, 301 - ROUQH PLUMBI�G
BuspdmC work,and the structure isnot ito's Ldedice offeredeLaw for sale(Sec. to 4.
an 502 — FINAL PRIJM@e' &p&HCsIRGY'
owner of pandro,Professions Code:The Contractor's License Law docs not erk1hi I°an
„sun rep his
p at d n d n workhimself
of
of through507 FINAL PLUMBING
coiale If however.
rb.p Wilding ci d that h p tt'intended of
o _
--offered ff within y - -- -- - - t,
improve
completion,pa b IJ 'lIM1 theburden
Iproving that h did not b le or 1
rep far parapose f 1 )
❑1 flhs.Property, .Ily I I g 1M1 licensed P Irstu
consumer rheim n (Sec.Ito a Business d Rv( de 7
Ione CoThCombatant's
License Law does not apply I r of property omen ho builds p a the
.and who Licence for such projects with t t refs)licensed pursuant I the .. _ .. . . .. ._.. -
CoInnnors License
/
❑tem cum Sc .BffiPCfonhrs reason -Ji`�
_ Owner Dam //
ER'S COMPENS/TION DECLARATION/2 /
I hereby affirm under penalty of Perjpry one of the following declarations:
I I have and will maintain a Certificate of Consent to self-insure for Worker's
ompcmmion, as provided for by Section 3700 of he labor Code, for the
pe,f..cc of the work for which this permit is issued..
_ °1 have and will'mainiain Worker's Compcmation Ins°mnce,as required by Section
1700 of the labor Code,for the performance of the work for which this permit is
issued.M Workers Compemation Insurance tamer and Policy number tie:
arsiec' t 1.,n I".:Policy No.: ull'_' ., a
CERTIFICATION OF,EXEMPTION FROM ORKES` r 'J*` S :ira-+.. � t�•1Z ILi•f? :'ta::+. .r •.. '.r,
COMPENSATION INSURANCE." - r ._-_._.__.. ........... _........___..._..-_ _.._.._.... ..._-._ .. .. ._ _.
.• - _ _ .. .ter. _, ... . ....... __. . .._._ _ . _.
(Thissectimn need nm be rnmplcmd if the permit is for one hundred dollen I'1 'n� -'
(SIM)or less.)
- 1 certify that in the performance of the work for which this permll is issued.1
shall nor employ any pcovain in any manner so as to hccome subject to the Works&
Compensation Law,of Cnlifomia.Dole
Applicant f - .. .. _.. ._. ..
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
bccmme subject to the Worker's Compensation provisions of the Labor Calc,you must
Q O f°nhwim comply with itch provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there iia contraction lending agency for the performance
W 6f the work for which this permit is issued(Sec.309],Civ.C.) -
'O. Lerder'e Name'. . ....-. .,.-.. ., .. .. .. .. .. _ _
Q.Z Lender's Address,
4.7 1 certify that I hove read this application and state that the above infurrai is
I:,'F center.I agree to comply with all city and county ordinances and state laws relating
O U res Wilding comirucimml and hereby authorize representatives ofif city to enter upon
W], the above mentioned property for inspection purposes. (/.
r G (We)agar,to save:indemnify and keep Wordless the City of Cupertino agaimr v
liabilities,judgments,costs and c Sicasca which may in any way accrue against said
U .Z. Grey is oreepance ofrhe gn of this permit. 7 ec'�
APUeCA U STA' AND WILL COMPLY WITH ALL NON-POINT' Issued by: Date Z2--
Sign-!
/ P
gnater nvcm'in eto Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
..:•
Will the applicamr orfurore wilding. at nom or handle neiadnta,mma;al Type of Roof _ .. -' -- •- - , .
so,defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Cede.Section 25532V):';.`. sin't" ) _. ` .I . else 1ti:, ,k
ores ' All.roofs Shall be inspected prior to.any.roofing.material being installed._. .__
Amokw'm the a,Pfic.nl or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,'I'agree to remove
mit hazardous air crominnnt as defined by the Bay Area Air Quarry Management
iswe? _. all new materials for inspection. Applicant understands and will comply with, .
°i'°' N° all non-point source regulations.
I have read the h6z dui matari 1 quimmems under Chapter 6.95 6f
Califomia Health&Safety Cod,Sections 25505.25533 and 25530.1•undersrand thin
it thebaildingdom not=ml itherin,In.,if my respomibild,mnotifylhe
aecupam of the r rare n left must he'met prior to issuance of a Ccni acme of
` "`y. Signature of Applicant Date
1' zed agrnr Dam All roof coverings to be Class "B"or better
:.. �� , •' -a,:.,. .. .... .., .. . OFFICE'