08010024 CITY OF CUPERTINOBUILDING DIVISION PERMIT GUk 'PI2r�.CTURIIF' RIA' TQ�N, :;:
Bua41bc�DR955:STELL ING RD ALL NSEASONS REMODELING 0801MIT 0024
OWNER'S NAME: PERM)T I SUEDATE
MR. DHULIPALA 219 DEMPSEY RD 01/29/2008
ONE: - SANITARY NO. CONTROL NO.
(408) 946-4744
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Op
LICENSEDCONTBACnderp DECLARATION
1 Wreby affirm Nat 1 am Iiceved under provisions of Chapter rt forommenefinglim=is Job Description
wim3ectian7g10)af0iv{aonitufmaBuanrsaverPf "Amonscode.ammylieenxb ADD 11 'X16 ' SUNROOM-NO FIRE FINAL NEEDED PER WES
n in full tome and
Lmenx Class Z — 1/09/08 .
Dae Comamar rrWftzr
3ARCHITECTS DECLARATION
I understand my plans thall W tend as public mcoNa
5p Licensed Professional -
OWNER-BUILDER DECLARATION
I hereby alum Not I am exempt Item the Commctors License Law far the
ZOO following moan-(Section 7031.5,Business and Professions Cc&:Any city air county
$ which requires a permit w c xormuc4 alter,impmve.demolish,or repair any structure
Prior An its issuance.alit requires theaPylieant for such permit to file a signed statement
< pursuant to the prolumen of the Comuactml License Law 9 SQ Ft.Floor Area Valuation
(commencing with Section 70(10)of Division 3 of the Business and Profetsians Cade)or $10000
that he is licensed p
S that he is exempt tis mfrom and the bub for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit tubjcc s the applicant to a civil penalty ofNumber Occupancy not mom than five hundred dollars(M). 36227036 P yType
❑Les enamor of Ili,property,our my ctoployees with wags as their sole compettudon,
will do the work,and theamcture is noinended or offered ronaca(Sm.7041,Business Required Inspections
and Professiotu Code:The Conumnstm'a License Law does not apply to an owner of Q p
property,who Wildsorimpmwa therean,andwho doessnch aarkhimselfor through his
mvn employees,provided dlalsuch improvements am not intended mo limed formic.U.
however,me building or Improvement is sold within one war of completion,the owner.
builder will have the louden of proving mal W did act Mid or improve for purpose of
sale.).
❑I,a owncr of the property am exclusively contracting with licensed carmons to
construct me pmjem(Sec.7014,Business and Professions Code:)The Contractor's V-
'mm Law does not apply to an owner of property who Wilds or Improve theme,and.
who conuac4 for such projects with a cmuanor(s)licensed puruwnt tome Communes
License Law.
❑Iamexemptundm5m, ,Bh PCfxrthismvon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury me of de following declaradoem
I have and will manuin a Cenifioe of Conserv to self-loom fat WmkchCampcn-
mfon,as provided far by Section 3700 of the labor Code,for IW performance of the
work for which this Permit is issued.
❑I have and will mainlan Worker's Compensation Insurance,as required by Section
3700 of mA labor Cade,for the perfomana of the work for which oris permit is issued '
My Workers Compensation Insurance carrier and Policy number are:
Carrier. 'Ijki'1 GI"._jtZ Policy No.:EIOt'1�I11KA 8OOI�
CERTIFl�EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
club ancdm need not W compleed if the permit is feature hundred dollars(SIM) ,
or Ices)
1 certify that in the performance of the work for which this Permit is issued,1 shall not
emplcy any person in any mmncrm u to Wcomo subject to the Wargcri Compcnsatim
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you mould
became Wbject to the Worker's COMPensdtion provision,of the Labor Code,you must
.J O forthwith comply with such provisions or this permit Nall W Owned mwkcd.
'Z'n CONSTRUCTION LENDING AGENCY
ti
[-+ IWr which
themembaed(Scc30 lending agency for the Performance of
Ri theLa work for which this permit it issued(Sec 3(19'1,Civ.C.)
W�Q Lender's Name
�Z Lender:Address
U Q 1 certify that I have mad this applicaWn And sum that the aWw information is
ty U coma I agree to comply with a1 city and county andinances and stem laws misting to
-� Wilding construction.and hemby authotiw rePmmntali ofthb city to Amer upon dre
W ahme-mcniumcd pmperty for impecdon putimses
g1. (We)agree to saw,indemnify and keep homeless the City of Cupertino against
vn h liabilities,judgments,costs and expcoea which may in my way accrue asa of mid City t
V 7 in consequence of the Starting of this pemlt.
v7 APgPLICC�AN'r UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:S Date
s�LIM nle 1 /y��(�y Re-roofs
Signature of ApplianVCommador Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WILT use applicant or furore building occupant some orhandca haardoes munria
u de0ned by the Cupertino Municipal Code,Chapter 9.13,and the Heath and Safety
cm1A,Section Yes
sss3z(.)7
❑ All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or toreNo Wilding occupant use cqulpment or devices which If a roof is installed without first obtaining an inspection,.I agree to remove
emit hazardous air contaminants as defncd by me Bay Amo Air Quaify Management all new materials for inspection.
Dbuict7 //
C]Yea f6Nu
1 have mal the hazardous materials requirements underChapar6.95 of the Califon
nia HesW&.Salle yCede,Sections 25505,25533 and25534.I undersand thaifthe balding
does not cumody haw a cannot.that it b my msPOOSARity to notify the omupant of the
re tri�mSnu Air et�HIe^r m issuance of a Cmifsaw of Oc an
��/UtXyVW l L� I f°i � Signature of Applicant Dale
Owner or authoirml agent Dae- All roof coverings to be Class"B"or better