04040066 CITY OF CUPEI1TINO
BUILDING DIVISION PERMIT �CONTRACTOR`INEORMATIO N:
BUILDING ADDRESS: MISSION DEVELOPMENT CORP PERMIT N0.04040066
FnRn
ER'S NAME: PERMIT ISSUE DATE
PALANIAPPAN KARVPPANCHETTY 43197 OSGO D RD 2004
NE: SANITARY NO. CONTROL NO.
(510) 657-4777
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
'oo
LICENSEDdmilmOnreec CONTRACTORS DECLARATION
p 1 i by affum that l am licensed under pt�rPinn:nr sham=r 9 anmmenung Job Description
n�d with Sue OnfDivision3of the BusincefactHWOfcssinns Codc.andmyliccnseis
j LI? in rear der I. 3a-yy REVISION--RELOCATE WASHER/DRYER
Llccnsc lass Lic.p
Date Contractor NO NEW PERMIT ISSUED/ORIG. 303120017
t qEq ARCHITECTS DECL ATION
yd a I urokorc m my plans shall be used as public reenfds
U
3 C y Licensed Professional
i < OWNER-BUILDER DECLARATION
E 10 I hereby.(Sere on 1 sur exempt from the Contractor's License Law for the
.p o which
mason.(Section 7(131.5,Business and Professions Code:Any city or county
I>; which reyuires a permit to construct,etre(,improve,demolish,or repair any,evucmre
_zY prions its issuance,also requires the applicant!orsuch permit to rile asigned statement .
gZ< that he is licensed pursuant the provisions of the Contractor's Limens,Law(Chapter 9 Sq.Ft. Floor Area Valuation $0
yH (commencing with Section 7000)of Division 3 of the Business and Professions Conte)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant le a civil penalty of
nor more men Bve hundred dollars(s5($500). APN Number QCCUane
). 36211031 .Number
0 Occupancy
Type
th
❑I,ss owner ofthe property,or my employees with wages as eir sole compensation,
will do the work,and On structure is not intended proffered for sale(Sec.70eK Business
and Professions Code:The Connector's License Law does not apply to an owner of Required Inspec T,
property who builds or improves thereon,and who does such work himselfor through his `
own employees,provided that such improvements are not intended of offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving chat he did not build or improve for purpose of +?;„
sale.).
❑1,as owner of fie property,am exclusively connecting with licensed contractors to ` /\
construct The project(Sec.7010 Business and Professions Code:)The Contractor's Li- v
came taw does not apply to an owner of property who builds or improves Neuron,and
who contracts for such projects with a eomractons)licensed pursuant to the Contractors
License Law.
❑1 am exempt under Sec. B&P C for this reason
at Dow
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declarations:
1 have and will maintain a CeniOcme of Consent to self insure for Worker's Compere
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37Wof the labor Code,for Ne performance of Ne work for which this permit is issued.
My Worker's nm enami �pScome,9 mer and Policy m,
Cartier PolisyOlt ?14ZN
CERTI gCATE OF EXE ION OMWORKERS'
COMPENSATION INSURANCE
Oris section need not bccompleted if the permit is for one hundred dollars($I00)
for less.)
1 sentry that in the performance of the work for which this permit is issued,I shall not
employ any Person in any manner so az To become subject o the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Corturnate of Exemption,you should
became subject to the Workers Compensation provisions of the labor Code,you must
.J O forthwith comply with such provisions or this Permit shall he deemed revoked.
Z y CONSTRUCTION LENDING AGENCY
(r I hereby affirm Nat there is a constrvetion lending agency for the performance of
C(.> the work for which this permit is issued(Sec.3W7,Civ,C.)
W�M Lender's Name
a z Lender's Address
U C 1 embly that 1 have read this application and state that the above information is
W F correct.I agree to comply with all city and county ordinances and suite laws relating to
building construction,and hereby aulhmire mpresemmivcs of his city to enter upon the
G amore-mentioned property for inspection purposes. -
(We)agree to now,indemnify and keep harmless the City of Cupertino against
iF'i N liabilities,judgmen¢costs and expenses which may in anyway accrue against said City
is
ot
U APPLICANTe oft TANDf tAND WI COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R LA ,s �1 N
%
Re-roofs
Signor ApplicanUCo act 'D
H R US MATERIALS DISCLOSURE Type Of ROOF
Will chcapplicantor turebuilding cecupanutorc or handle hararduus material
az defined by the Cupertino Municipal,Code.Chapter 9.12,and the Health and Safety
o1 Seaton 25532(.')? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future boldin ecupam use agwPmem or devmex wMch If a roof is installed without first obtaining an inspection,I agree to remove
,it hazardous air contaminants az Jcf by the Bay Arca Air Quality Management all new materials for inspection.
ixbon
❑Yes s
I have rand thea
Is rcyvircmen¢under Chapwr6.95oftheCalifon
niaHcalth&Sa o ,25533.d25534.1.ndcrsWdtl atirOchuilding
diesnotcu nt as my respomibilby to notiy the ncupsnt nl'the
myuirmc taissuanceforscanlfcion, ccuanrySignature of Applicant - Date
41- All roof coverings to be Class "B" or better
Owner ser auuhorizcd ,tc