04090287 . CITY OF CUPERTINO - t;}' " " ` -' �^'*'^ ` w
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'BUILDING DIVISION PF.RM� W� l,. 1F�.�11ic L1M} A\
BUILDING ADDRESS: - DAVID VALVERDE PERMIT"'04090287
OWNEWS'NAME: - - PERMITISSUEDATE
SURJIT KAU -
E:'
SANITARY O. i0,01 NO. "
ARCHITECT7ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo - LICENSED CONTRACTOR'S DECLARATION - Job Description
-
1 hcmbY affirm Ihat I em banded under Provisions of Chepmr 9(commencing _ .. .
-� with Section 7011h.f Division 3 oflhe Businee aM Professions Coda,and my license is -'- - -
'oZ, mfull nmhaand mere. - REVISION--RELOCATE BATH DOOR
Z License Clam Con tr
Date TSDECr REMODEL LUNDR. RM/LINEN CLOSET `�
ARCHITECTS DECLARATION
jj< tlrsundmyplam¢he11M1 uudaspuM1licrccntl NO NEW PERMIT I$$UED/' ORIG" '#04 0 2 0 15 5—'- - --
;o� Licensed Prefeeional - - - _- - `
9 S OWNER-BUILDER DECLARATION
9 .1 hereby affirm that I am eacropt from the Connector.License Law,for the -
❑o following reason.(Section 7031.5,Business and Professions Code:Any city or county
K m 2 which requires a permit to cnnabuct..heq improve,demolish.m repair any ammium
,a prior..its ismance,also requires the applicant forsuch permit m Bic.signed Otement
ss< than he is licensed pursuant W We previsions of the Comment's License Law(Chapter 9 Sq.Ft.Floor Area Valuation .
xF� (commencing with Section 7000)of Division 3 of We Busincssand Professions Code)to
that he is eumpt thcrefmm and the bola for she alleged exemption.Any violation of 80 _
Section 7031.5 by any applicant for a permit subjecu the applicant 10 a civil penalty of APN Number Occupancy Type -
act more Nan five hundred dollars($500).
❑Las owner ofthe property,or my employees with wages as their sale compensation,
will do the work and theabuctue,is not intended moffead formic(Sec.7044,Business - -'
and Professions Code:The Commuter's License Law docs not apply W an owner of Required Inspections .. . ._
property who builds orimproves thereon,andwhodmasuchwork himselfor through his
own amployces.provided haunch improvemenu.vent intended oroQered for sale,If,builder
ill ban the burden
of pmentlshat he titin of Wild of..prow,for
I purpose
f
builder will have the burden of proving Net he did not builtl or improve for purpose of
5p�1.
sale.//).
m owner of the property,am exclusively contracting with licensed convectors to
cSnsuuct the project(Sec.7044.Business and Professions Code:)The Conmemr's U. _
.nae Law docs not apply W an owner of property who builds or improves thereon.and.
who contracts for such projects with aconvachu(a)licensed pursuant W the Conmctors,
License Law. - -. ._ -
❑l ado exempt under Sec. - BB PC for this notion
1Owae "a Data 0
W ATIO EC RATION
I hereby eRm under penalty of perjury Aof the following declensions:
have and will him ulna Canitiesmof Conunite self-insureforWorker'sCompen-
more.as provided for by Section 3700 of the Labor Cade,for.the performance of We
work for which this permit is issued,
❑I have and will maintain Workers Compensation Insurance,m required by Section -
3700 of We labor Code,for the poneorma of Ne work for which Nis permit is iuued.
My Worker's Compensation Insurance carrier and Policy number am:
Came,. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(This auction mad not Wcumplemd link Permit is forunc hundred dollars(SI W)
or less.)
I carry that in the performance of the work for which this Permit is issued,I shall not - -
employ any person in any manner an as to become subject o the Workers'Compensation
Laws of California.Dat
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you AWW -
became object 19 the Worker's Compensation provisions of We Labor Cnde,yen mum
.JO forthwith comply with such provisions or this permit shall he deemed revoked.
Z CONSTRUCTION LENDING AGENCY '
HIWomy afTtrm but We.1.a....traction lending agency or We perfrrmmce of
!Yi r7 me work for which this permit is issued(Sec.3097,Civ.C.) -
{g1 Q Lender's Name
z Lenders Address
U Q I comfy that I have read this application and sum that We show information is -
(L F Cancel.l agree to comply with all city and county ordinances and stet laws heading in
U building construction.and hereby embolism representatives of this city to enter upon We
W ahavc(We)agree
to property fm emnifyian lacep hs.
sy (We)agme ro save,indemnify and keep bay in m W City accrue
Cupertino against
fA inconsequence f tograuand expensce nit. may In any way eccroe against said City
A consequence of NI Renting of this pmmit.
r'^
SOURCE
UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Da
SOURCE REGULATIONS.
—l� / Re-roofs
Sr�e Applicant/ ommuctor 1 ^ Dat
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
t._ Will We applicant or future building occupant start or handle ho-emdous mamnal
as delmod by the Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
C
od e25532(a)?s31(a)7
[]Yes No�2 All roofs shall be inspected prior to any roofing material being installed. .
❑ �
Will me applicant or mem Wadding a trpaml use equipment or davi=ns we=b If a roof is installed without first obtaining an inspection,I agree to remove
I havardnas air contaminants ae defined by the Bay Arca Air Quality Management all new materials for inspection.
wool,
❑Yes ST No
I have mad We hazardous materialsmquiranum under Chaptr6.95 of the Califor.
me Head"Safety Cade,Sections 25505,25533 and 15534.1 undecound Wetifthe building ,
dace not currently hove a tenant War it is my responsibility w artery the occupant m We ..,_
rcyuimmcnu wChc mer pngrW issuafa CcniOcat ot«=yp /�y Signature of Applicant Date --
O cr or auNomcA agent /wry', -All roof coverings to be Class"Bre or better
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