04020154 CITY OF COPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.O F O 2 0 15 4
OWNER'S NAME: PBRMIT ISSUE DATE
NE:SURJIT KA — SANITARY OL NO.
ARCHITECTENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u o o LICENSED CONTRACT'OR'S DECLARATION Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing P
with Section]0(10)of Division 3 of 4,a Bulinus and Professions Code:and my license is
in fun force and effect. REMODEL--CONVERT LAUNDRY RM TO FULL BATHRM &
5 z„ Llamas Class Lt.,X
Croar r MOVE ENTRY DR & WINDOW TO THE OPPOSIT SIDE
Lau
ARCHITECTS DECLARATION
I understand my plans a bell Waxed as public cards REPLACE SLID.DR. W/REGULAR DR. /A WINDOW IN GARA
DyU
;p
Licensed Pm@ssionel
OWNER-BUILDER DECLARATION
1 hereby.(firm Net 1 1. exempt from the Cortins Co License Lew for the
to o following reown.permit
t IIOT.S Business and me,dernns Code:Any city or county
which requires a permit re ennstmq elute impmw,h para h,lire a sitandem
!z prior to its issuance.pursuatt 10 the theapplicant,forsucto CohpermiuLicenssigned sutemcm
Nn heanin used pursuant 7(thc provisions of theeBusheassand License Law(Chapter9 Sq.Ft.Floor Area Valuation
sC (commencing with Section 70)0)dDivision 3 o the Businessand Professions CoJe)ur .
$ that he Is attempt therefrom and de basis for the alleged exemption.Any violation of
Section 9031.5 by any applicant for a permit subjects do epPncant m a civil penalty of APN Number Occupancy Type
nam mom than Bw hundred delta.($500).
❑I'm oamar of the property,or my employ=with wages as deirula Compensation,
will do lAework cad dieaoucti n is multiheaded oro@red forsak(So..7W.Business 3 5 7 Q 3 UT5—. 0 0
and Professions Code:no Contractor's License Law does net apply to an owner of Required Inspections
prepay who wildsorimprown thereon,and whodoessuchwork himself or through his
own employces.provided thatsuch improvements art not Intended oroRend forsale.If,
however,the building or improvement is old within aro year of completion,the mares`
builder will haw de burden of proving that he did ant build or Improve for purpose of
sale J.
n 1,as owner of the property,am exclasiwly contracting with)leaned Contractors to
conic La the project(Sec.9044.owner
of and property
who
Code:)The Canwcur's nd
cense Lew cars not apply je an owner of property who sed p Or improm themes.uta
who contracts for such TmPets with a conuacur(a)Ilanud pursuant the Conuastoh
0L'eons Law. /
5 Ianempt under Sec.R.�e .B&PCfar thio on
wilco�s _ &dllTO^sy, r. ,� Date /
1 hereby affmn under penalty of perjury ane of the following declarations:
❑I haw and will maintain a Contrition of Consent to calf-insum for Workars Compete-
nation.as provided for by Section 3700 of the Labor Code,for the performance of the /y
work for which this permit is instead.
❑1 haw and will maintain Workers Compensation Insurance,as required by Section
3900 of the Labor Cede,far the performance of the work for which this permit Is issued.
My Workers Compensation Insurance carrier and Policy number are:
Camar: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nand not N completed if the permit Is formic hundnddollan(SIM)
or kis.)
1 certify that in the performance of the work for which this Permit at issued.I shall not
employ any person in any mannerso as to become subject o du Workea Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT':IL afar making this Cenificahc of Escmpiion,you should
become subject in the Worker's Compensation previsions of me Labor Code,you must
,J O forthwith comply with such provisions in this Permit shall to deemed n ml ed.
„z,�ti CONSTRUCTION LENDING AGENCY
[—i I hereby affirm that them is a Construction lending agency forme performuu of
tYi the work fur which this permit is issued(Sm.3099,Ci,C.)
W A tenders Nun.
z Lcnders Address
UQ 1 cosily that 1 have mad this application and sou that the above ulceration is
LU F Carlen I ag1Ce to comply with all city and county ordinances and state laws minting to
pU building construction,and hereby andante represemilim of this city to enter upon the
U aherve-mendoned property for inspection purposes.
(We)agree to save,indemnify and keep humlest the City of Cupertino against
j.y r%j Iiabilides.judgments,costs and expenses which may in Bmy way&ceme against mid City
U 7 mean uqucnce of the granting of this permit -
Fl APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC REG AMONS. st
O Re-roofs
ignadre of Applin UConuedor Oau
HAZARDOUS MATE LLS DISCLOSURE Type Of ROOF
Will the applicant or future building occupant store exhandlc hvereous mammal
as defined by the Cupertino Municipal Code.Chapter 9.13.and de Halm and Safety
Code,Section 35533(.)? All roofs shall be inspected prior to any roofing material being installed.
El Y. 9Nm,
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 han aures air conmminams as defied by the Bay Arca Air Quality Management .all new materials for Inspection.
District?
❑Yesu
Raw mad the haardoes madrialsrequimmena underChap er 6.95 critic Califon
ilia Halm&Safcty Coda,Sttamu 25505.35533 md853d.I unJcnund thaiddu building
doss not Comedy New a meant dim it is my responsibility to noal'y the atupanl of the
re iremcnlswhich vuhmetpdrtudana ofaccrificamofoccup y. Signature of Applicant Date
Owner lir aumomea agentD t. All roof coverings to be Class"B"or better