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CITY OF CUPERTINO
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BUILDING DIVISIONPERMIT
?2kCO1VTRACaTORI_NFORMATIO
BUILDING ADDRESS:
PERMR NO. 06020027
1462 ROSEGARDEN LA
EWS NAME:
PERMIT ISSUE DATE
ABHIJEET GOLE
06
NE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMS MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
wh1h Section 7000) ofDivision 3 of the Busineuand Professhuns Code, and my license t
innllto=andaffea
CONVERT CLOSET INTO. BATHROOM -NO MECHANICAL
License Class Lk. p
Dam Contractor
INCLUDES ELECTRICAL & PLUMBING
ARCHITECTS DECLARATION
I car ddrawrol my plans Mall be used as public records
j�+T
FINA
Licensed Pml.ional
OWNER -BUILDER DECLARATION
1 herebyaffirm Nm I em exempt from the Conuscmfs License Law far the
following reason. (Section 703 1.5, Business and Professions Code: Any city or county
�•nF,
which requires a permit to encounter, shut, improve, dcmolth, or repw any structure
prior to its issuance, iiw requires the applicant for such permit to Glc a signed suhement
Nat Its is licensed pursuant to the previsions of lW Contractor's License Law (Chapter 9
Sq. Ft. Floor Area All
(T Valua}9ilt18000
(commencing with Section 7") of Division 3 of0c Business and Professions Code) or
Nat he u exempt therefrom and the but for the alleged exemption Any violation of
ME
�":. ..
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of
APN Numberatowiff
) c Type
P?P y yp
net mom than five hundred dollars (Mr.
3661 7 0 0 8 . 0 0
tl
❑ 1, u owner of the pmpeny, a my employcu with wags u Nab wle comperation,
Required Inspections
will m Na work. and Naawmua is nor intended On offered renals (sea. road, Business
and PrefessioM Code: The Centel Lt.. Lew dos not apply w an owner of
property who buildsor improves thereon, andwho doessuch work himsehforthrough his
own cmplowu, provided Net such improvements are not intended oro0ered forsale. If.
however, the building or improvement is sold within one year of completion, the owner-
.
Witter wi0 have Na WrAcn of moving that be did nm build or improve for puryme of
sale.).
❑ I, o owner of the property, am exclmively contracting with licensed conuacuus to
construct the project (Sec. 7044, Business and Pmfcssiorr Code) The Contrumrs U.
cense Law does not apply an an owner of property who builds or improves Nemon, and.
who contacts for such projects with a contractor(s) licensed pursuant in the Contractors
LKCM1Y Law.
❑lam attempt under See B k PP C for this reason
C (7 L� Dau 6a)�)
UW�PNATON
FJ
DECLARATION
1 hereby affirm under focally of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workes
as provided for by Section 37M of the Labor Code, for the performance of the
work for which this pcfmit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3700,1 the labor Code. for Ne performance of Ne wart for which this permit abound.
'
My Workers ComPansedon Insurance carrier and Policy number are
Carrier. Policy No.:
,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(1Tt smite reed Out be completed ifthe remit t form= dollars (5100)
alas,,
_14 rd C:2 -AA .
unify Nat in the mane of Nc work Ins which Nis fcrmil t issoo4 I shall not
employ in any
pc ymanncr3oYm c n orken'Com Pcnsation
Laws of Calijor9y D�atF H ^ Vl 'FP�rnra /'I fi
Lawsof Ca
7W W
Applicant 1� )^�' t1I M�—
NOnCETOAPPLICANT: If, ether making this Cer ifcam of Exemption. you should
become subject en Na Werker's Compmtsaaon provisions of the Libor Cods you mute
forthwith comply with such pmvisions or his permit shall be deemed raveled.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that thea is a convection lending.germy for the performance of
IM work for which this permit is usucd (Ser. 3041, Civ. C.)
Lender's Name
Under's Address
I certify that 1 have nad this application and sum wt the stow mmtensom is
COMM I agnea to comply with all city and county ordinances and sun laws relating to
Wilding convection, and hereby auNorim MPTOMRtiu a of this city w enter upon Nee
alwvocajudeedproperty for inspection purposes
(Wee) agree m ave, indemnify and keep harmless Ne City of Cupertino against
loanandeapntseswhich may in any way accrue against said City
IiaNlides,crard
o the Ning of this permit.
of UNDERSTANDS
A APPLICANT
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date r1
SOURCE REGULATIONS.
6
----V
Re -roofs l �
!t'�N l :t )✓'�f C1 b L i 1)7
Signature o(ApplicaHAZARDO Dau
to
HAL, MATERIALS DISCLOSURE
Type of Roof
Will Ne run. t
or faun building a handle boathouse material
a Cucanl
u defined by e. Chaperon
Cupertino Municipal Code. Chapter 9.12, and the Health wJ Safety
. Section 25332(,)?
25
❑tea ON.
All roofs shall be inspected prior to any roofing material being installed.
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
crit havafdnus air contaminants as dcGncd by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes ON.
I have mad the haardousmamrials requirements under Chapter A95 offt Califor-
nuHeil" SafelCode, Seetian25505.25533 and 2553x. lundcrsand Nztifdm Wilding
does out currently haw a cont, that it t my responsibility m treaty de occupws of Ne
reghremems which must be met our to issuance ofe Ccnficahe of Occ ver.
Signature of Applicant Date
4V UP' DZo6�b�
All roof coverings to be Class 'B" or better
Owner or authored agent Dahe