03040042 CITY OF CUPERTINO ax ' '""'_* �' �' - '''♦ I'`�T '
BUILDING DIVISION PERMIT CONTRA CCU IN MATTt�1V. ;
BUILDINOADDRESS: PERMIT NO.
22681 SAN JUAN RD DUSITYANT PANDYA 03040042
OWNER'S NAME: PERMIT ISSUE DATE
DUSITYANT PANDYA 04/07/2003
E: SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDO ELECT- PLUMB MECH
moo LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provision of Chapter 9(commencing Job Description
with Section 7011)nfOivldon 3 ofthe Business and Professions Code.and my license is p /y
n 6 in fall force and effect. �'e\• OY �C®
Sig Lice.Clue uc.g DECK REPLACEMENT V t.1
z F Iundcntandmypi
Date Contractor
3F ARCHITECTS DECLARATION
NS ns shall he used as public record. MAY 12 2003
Licensed Pmfcaim al
OWNER-BUILDER DECLARATION BUILDING
2 1,herebymasa .affamsscot that f 1. exempt from to Contractor's r,License Law for the
a O follmvinC mason.(Scotian 7113L5,Business seri Pro(easlon Cade:Any city at county
$ which requtres a Permit to conduct,alma impmw,demolish,our repair any fracture
prim In its issuance,also mquies the applicant retouch permit to rile a signed statement
that he is licensed pursuant to the provision of the Cenrracl"jLicen,law chapter Sq.Ft, Floor Area $ Valuation
gF❑ (commencing wit Section 7000)of Division 3 of the Business and Professions Code)or 20000
3$ tat he Is exempt therefrom and to Was for to alleged exemption.Any violation of
Section 7031.5 by any applicant for a penult subjects the Applicant 10 a civil penalty of3�p Iji l t 0 0 Occupancy Type
ore
not mthan neve hundred dollars(S5010). y
❑1,uowncroftepmpcny,ormycmploymawithwagnutehaolewmpenudon,
will do Ihewo k.and thence..b ma mended oroRerad tarsale(Sm.7044,Buai.
and Propellors Cade:The Contractor,License Law does not apply to an owner of 101 - FOUNDA904W Inspections
property who builds orimprevrs thereon,•nderhodoeuuch work himeelforthrough his 102 - PIERS
Own employees,provided tat such Improvements am not intended or offered for ole.if.
however,the building or improvement is cold within one your of completion.the Owner' 103 — UFER
builder willhave the burden of proving to he did not build or improve for purpose of
cam.). 104 - REBAR
❑1,as owner of rite property,am exclusively connoting with licensed com uc ors to 105 - ANCHOR BOLTS
construct Ota,project(Sec.7044,Business and Pro(esalUaa Cade:)The Comment's Li. lO6 — SEWER & WATER
cone Law does net apply to an owner of property who builds or improves,themes,sed,
who contracts such projects withacontraclm(s)licensed pursuant m to Commutes 202 - UNDERFLOOR PLUMBING
rose Law. 203 - UNDERFLOOR MECHANICAL
lam Law.
and Sec. —�—�—�— B&PCfor this reuAn
�USlo/D,ts ,107/v3 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATON 205 - UNDERFLOOR INSULATION
I hereby affirm under Knotty of peduryrnco(tefn11owdo larthms: 301 — ROUGH PLUMBING
sew and will maintain a Certificate of Consent m se161uure for Workers ComPen- 302 ' — TUB & OR SHOWER
n,u provided for by Section 3700 of the labor Code,for to performance of the
work for which this permit m Issued. 303 - ROUGH MECHANICAL
❑T haw and will maintain Worker's Compensation Insurance,as required by Section 304 — ROUGH ELECTRICAL
37M of the Labor Code.for the Performance of the wort,for which this Permit Is Wood. 305 ' - FRAME
My Workers Compwsallon Insurance carrier and Polley number am:
Carrier. Policy No.t 306 - HOLDOWNS
CERTIFICATE OF EXEM MON FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE
(This auction need not becompleted ifte Formal is teras,hundmddollaaniffn 308 — SHEETROCK
"lose) 309 - EXTERIOR LATH
1 cemify that in-4.1tnrfrmunw of the work for which this permit B issued.I shall not 310 - INTERIOR LATH
employ any dun my manors a o ewbjec to the Workers'Compcnsnion
Laws OfcaliIa.Dow b� 311 - SCRATCH COAT
" p'i•^' u` Y � 313 ' - ROOF NAIL
NQI'IC�TO APPLICANT;IL afkr making This Ccrtl tote of Exemption,yo should '
beMhdlF-abject t the Worker's Compensation provision of tc labor Code,you mat 501 - FINAL ELECTRICAL ENERGY
ozp re wttwmPlywOnaa,bpm.itinnsmw,prmR.n.nbeawmeamnkee. 502 FINAL PLUMBING ENERGY
ZCON6TRUCTIONLENDINGAOENCY 503 - FINAL MECHANICAL ENERGY
[ti r IMmhyannnm tat there is a construction lending agency forte performance of
eG to work for which this Permit Is issued(Sec.3W7.Civ.C.) 504 - FINAL BUILDING ENERGY
W Ga tnd,eaNamc 505 - FINAL ELECTRICAL
z Lonaer'sAddrea
U O I family that 1 haw read His application and state that the above mimmation is 506 — GAS TEST
OF correct.I agree to comply with all city and county ordinances and sum laws totaling toCj 7 — FINAL PLUMBING
U building conswction,and hereby autodm mprnemadves of this city to enter upon the
W shove-mentmndproperty for Inspectionrarpnsea —
0 FIN L MEC ICAL
LL (We)agree to saw,indemnify and keep harmless the City of Cupertino agalnl 9 FI
n.t fA liabilities.judgments,costs and expenses which may In any way accrue against said City
U`X In consequence of the Sousing of this permll.
F7 APPLICANT UNDERSTANDS AND WILL
yCs{IRMPLYyfWITH ALL NEON-POINT Issued by: 5 NG Date
4A
SOURCE EA�tl-Y Vm'�`sAO m�l� 1�d) _
_�(:f�11 Re-roofs
Sign um of Applic HA2ADOUS MATERIALS DISCLOURE Data Type of Roof
Will to applicant or future building occupant some or handle havudous material
as donned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Swoon 25533(a)7
❑You PRI No All roofs shall be inspected prior to any roofing material being installed.
T If a roof is installed without.first obtaining an inspection,I agree to remove
Sk Will the applicant.at future building occupant use equipment or devicmg which
haardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
ict1 ,,,,,,,,,,,,������iillll
❑Yea - �iNo
I have mad the haramious matrialsmquimmcn;unduChnor6.95 of the Califon
nm Nc il"SareiyC^dc.Sectimu 25505.35533 md25534.I understand Out lithe building
ticer not currently haw a tenant,that it is my responsibility in notify the mcupmt m the
uircm9�a Which must be mmp^or miaumeeola CcniOcamor Occu a
QAW� s.+ � 4 pry d5 Signature of Applicant Date
M0
Owner or authorized agent Date All roof coverings to be Class oBo or better