06040098 CITY OF CUPERTINO ° '''< 7�7* " '
BUILDING DIVISION PERMIT �CtONTRAGT,OR I.NF,URMATI N
BUILDING ADDRESS: PERMIT NO.
SRIDHAR PALLA 06040098
O4KQd1AFMETONITA WY PERMIT ISSUE DATE
NE: _ SANITARY N0 5 3 0 2(D@VL NO.
ARCHIIECDENCINEER: BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
ip LICENSED CONTRACTOR'S DECLARATION Job Description
C 1 hereby affirm that 1 am liensed under provisions of Chapter 9(commencing P
b wiW section 7000)of Division 3 ofJe Business;and Pro2crioru Code.and my liccnuu
in full to=and effort.
3 Lmcn=Clma Lle.N ADDITION 597 ' -BEDROOM/LIVING RM/COMPUTER ROOM
Dam.Contractor
ARCHnECrSDECLARATON PORCH 67 ' -REMODEL KITCHEN
�a I understand my plans shell he used as public rteor&
U
h LiccnuJ Pmfaxianal
n3 Oat I am exempt
trend
DECLARATION
f 1 hereby affirm that 1 accept tram Ne ContractorsLicense: c law for the
10 following uason.(Section 7031.54 Business and improve.
do io li Calc:Any city or county
e v, which requirof•permit re trims a star,hnpmve,h permit B or mash any mactum
priors its Issuance.elxaesquires he previsions;
for such permit laflessigned summmr
that hecnieenwt SOcuant to the or Division
offive ofe (Chapter 9 odc)or Sq.Ft. Floor Area Valuation
(canmoncing with Smuon]000)of Division 3 of IW Business and Professions Code)or
$131755
3 S that he is esrmpt duced.and the basis for the alleged exception.An,violation of
Section 7031.5 by any appllum for a permit subjects the applicant to a civil penalty,of APN Number Occupancy e
eta mots Nen five hundred dollen(55004
P Y EYP
1,as,cones of Ne property,or my employees with wages as their sole compenssd it. on
will do the weak.and theatrctum uIMEmu Bled oroffered frdsale(Sec.7040.Busiruss
and Pm(eash ns CdO TW Conuscwfs Limtse law dots tet apply to an comm,or Req 'r Inspections
property who Wilds orimprows mereou,and whodocssuch work himselforum lb his
own employees,provided that such improvements au not intended reoffered forsale B,
however.Ne Wilding ed did
arc leer or mproeforn.the ore of
Wilder will have the burden of proving that W did not build m improve for purpose of /C/
F1,u owner of the property,am exclusively contracting with licensed mrsnoacwas X
rammer the project(Sec.7044,Buena end property
whootn Code:)The ConoeeWs um CJ
cane Iso dais not apply,an with
0 N mt r(y who W ads ra improves Ct mnse aha.
who mnuacts for ammb pmjear with a eonuactor(s)licensed pumuem w the ContnnoYs
Licensemlaw.
❑1 am amnpt undo Sec B&P C for Nu teasov
OwnerDau
'VNER!S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury orc of the following declamations:
1 have and will mountain.Cenificam o(Coasent to u16inwu for Worker's Compete
cation,as provided for by Section 3700 of the Labor Cade,for the performance of dm
wart for which this permit is issued.
1 have and will maintain Worker.Competaetion Insurance,as requited by Section
3700 of the LaWr Code,for the performance clubs work for which his Permit is issued.
My Worker's Compemadon hnurance artier and Policy number are:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
films srmtlon mored not W complemd if rte permit is fm one hu ulmd dollars(5100)
or less)
1 cerli(y that in the performance of the work for which this Permit u issued,1 shall not
employ anyperson in any menxr u as to become subjrct to dm Workers'Com�[musdon
Laws of Califarnm Oatc M
Applicant t Y: a G
NOTICE TO APPLICANT:If,after making this Cenifate of Eacropmo.you should
become subject to the WMIkeri Compensation provisions of he Labor Code,you must
OfoMwith comply with such provisions or this permit shall W deemed revoked.
VI CONSTRUCTION LENDING AGENCY
I hereby aRm team them is a constrnion lending agency for he performance N
the work For which this permit Is issued(See.3037,Civ.C.)
ALetume,Name
Z I<naerk Address '
0 1 certify hat 1 have mad this application end sum that the aWve Woodshed is
correct.1 am comply mply with all city and county Melodramaand state laws misting to
VWilding construction,and hereby auuborlre¢pmsveamnS of this city to enter upon 0e
above-mentioned property rot inspection purpouu
m gy (We)ague In eve.Indemnify and keep harmless the City of Capstone agsirtst
fn Iisbiliues,judgmen6,coms and expenses which may in any way me=againslsaid City
I Z in consequence of the grunting of this Permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 7 v
SOURCE REG S.
0 6 Re-roofs
Sigmtu or ranuCon r Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant nom or handle hawdous material
as defined by he Cupertino Municipal Code.Chapter 9.13.and the Health and Safety
Cole,Section 25532(e)7 All roofs shall be inspected nor to an roofing material being
❑Yes NO P P Y g g 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
It havardnus air conmmimtants as dcancd by the Bay Arta Air Quality Management all new materials for inspection.
Dieu e7
❑Yea Pied
1 have mad the ho ammca materials requirements under Chapter 6.95 or the ctum,
nia Healdm&Safety Code,Sccdom 25505.35533 and 25534.1 understand that ifthc Wilding
does not cwundy have a meant.not it u my responsibility m oddly the occupant of the
requimroc y��home Ow metimorwiamaaccoracatircamera Signature of Applicant Date
^erauthmmmd�t dn pate Dao b All roof coverings to be Class"B"or better
'