05070110 CITY OF CUPERTINO k `z, r craw. ^
BUILDING DIVISION PERMIT COx "TRA"OTOR 110.10 tMA.TIQNt„
BUILDING ADDRESS: NEELIKA CHOUDHURY PERMrT N005070110
49c; TnDITTA WV
ER'S NAME: PERMIT ISSUE DATA
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PHONE; SANITARY O. C NTROL NO.
ARCHITEC IENGINEEW BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
goo LICENSED CONTRACTOR'S DECLARATION thJob Description
1 hereby M. 1 u
n licensed under provisions or Chapter 9(commencing
^� cord Sffirm ection 7070)of Division 3 of the Bomms nnl Profession Code.and my Ileeme is
,� in full fora and efface
pz Lieenmclaas Ix.g CONVERTING 2 EXISTING WINDOWS INTO DOORS . .
-- Dam Contractor ONE SLIDING/ONE REGU
e
ARCHITECTSuse u DECORATION 'w QAL�understood
Wuse
y 1 under
nJ my plana shald Cosine records '`a,
g
udt; Licensed Professional
OWNER-BUILDER DECLARATION )
E I hereby affirm thm I am exempt from the Contractor's License Law for the rs005
O following mason.(Section 70313,Business and Pmfcuinm Code:Any city or county L
132 which requlms•permit to construct,alter.Wpmw,demolixh,or mar my structure s
prior W its isamnce,also requires the applicant fanuch permit W file asigned comment
-ppss< that he is licensed pursumuo the provision of the ConuxtofaLcenm Law(Chapter 9 Sq.Ft.Floor Area 200
YF� (commencing with Section 7000)of Divldon 3 ofthc Budncuml Profession Cwle)or
— dot he W exempt tiomfrom and the basis for the alleged Bump ion.Any violation of
Semon 7031.5 by my applicant fora permit subjects the applicant to a evil penalty of APN Number OcCupiffTcy,Type
not mom Nm five hundred doll..($500).
❑Luuwarof the property,or Is emntendeh with ages utheir role compensation,
35914009 . 00
willde due work.ands;Th.0 mhawl Limmeed Law
do for
not apply to an Owner
ss
Of Required Inspections
and Prorwhobu Cade:The C,themor'h License law alas or apply lf rt owner is q P
Ownproertywhas.lds provided that such
who arc not chwork araelred for ll,le his ,
own employees,provided maumhimprowmenu..notyear
ofIntended maaered the Owner.
however,the building or improvement Is hold a did
one year ofI mmue for the owner
builder will hew me burden of proving that Iso did rot build or improv for purpose of
i,as owner of the property,am exclusively contracting with Licenced convumn to
mnsi mcl the project(Sec.7044.Business and Profession Code•,)The Contractors LI-
cene Law does not apply In an owner of property who build,or improves Ihemon,and,
who conuacu for such pr*co with a conuactar(0 licensed pursuant W the Contrmtael
License Law.
❑i am unmpt under Sec. .B @ P C for this reason
r Mu.Ulluf. C P�Date 7
WORKEWSCOMPENSATIONDEC ATION
1 hereby affirm under peaty of perjury oro of the following decl..don:
I have and will maintain aCeNflnm of Consent W self-inum for WorkeesCwnpen-
nation,Is,provided for by Section 37M of the Labor Code,for the aAormmm of the
work for which this permit is Issued
❑1 have and will maintain Workers Compensation Innvana,as required by section
3700 of the Labor Code,for the perforrummotthe work for which this permit is Issued.
My Workers Compensation Inursnm stonier and Policy number art:
Cerner. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rota uctimr aced not Wcomplemd If tie permit is For onchundred dollars(SIM)
or len.) ,
1 ceNfy that in the performance of the work for which this permit is Weed.I shall not
employ any person In my to crwumbwomc subject W the Workers'Compensation
U.S.1'Califomia em ��fft'/ OS
Applicant Mag;ll r�P . ,
NOTICE&PLICANT:IL atter making N C9r0Emo of topium.you ahad
become subject W the Worker's Compensation provisions of the IAMr Code,you mug -
,J O forthwith comply with men Provision or suis permit shall he doomed revoked.
z ti CONSTRUCTION LENDING AGENCY
F' Ihereby affirm that Ilea its mnwcinn lending agency for the performance of
OC the work for which rob permit Is issued(Sec.3097,Civ.C.)
W Q Lenders Name
ra�7- Z Lenders Add.
U OF 1 cenIfy the 1 haw mad this application and sou that the above information b
ty U correct.I spm to comply with all city and county ordinances and sou lawn relating W
C building convection.and hereby aumoriu representatives of this city to crier upon the
W above-mentioned property for InpeNan purpo¢s
(We)agree to save,indemnity and keep humlw the City of Cupertino against
Taj) Itabilitlu,judgments,costs and expenses which may In my way memo against Said City
U Z in consequence of the granting of this permit.
w. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date ��S
s4a L
SOURCE
IL, e- In1 t =AM 7/�g
� Re-roofs
Si ureofApplimn/Conuor - Dam Type of RoofHARDOUS MATERIAS DISCL URE /
,
Will mcapplicant or future building uccupanumrc or handle haurdoos mamrial -
u defined by the Cupenino Municipal Code.Chapter 9.13,and the Health and Safely
•.Section 25532(x)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes $No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haraNnu air contaminants u defend by the Bay Am,Air Quality Management all new materials for inspection.
District?
❑Yes 5(Nu
I have mad me hUJAM3 materials reyumenenu under Chapter Q95 of the Califor.
rota Health B Safety Cade,Sectors 25505.23533a 425534.1 undersoM that irmc building
does Out currently haw a mama that It u my rmpon a lily W muly do oc upant of the
requiremcnywbichmuubcyjeipriwWi uanccofaccrdate.f Occupancy. gna[Uie of Applicant Date
t. JAI 7 I DSj
0 or or authorized age.. U Dam All roof coverings to be Class'B" or better