00120058J
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRLSS; 4 III' U. —.
10231 WESTERN DR PRASAD RAYASAM S AND �YfC� R00120058
OWNER'S NAME: APPLICATI(,)G/rl All , 000
PRASAD RAYASAM S AND SITA R ���
°HOffi;: SANITARY NO, CONTROL NO.
o¢z Akcnl'I 1iCl'/ENGINIiIiR: BUHLNG PERMIT INFO
Woo❑❑ BLDG ELECT' PLUSIB MECH
FF'Oc W =I' IJ l-1 1_1
O LICIiNSED CONTRACIOR'S DECLARATION Job Description
y_o I hcmhy affirm(hat];at,liremcd under pnrviaions of Chupror 9(commencing
F_(=.Iq wi. ....ion]IYM)of Division 3af the Ousincs and Prnrczsinm Q,Je.unJ myliceme PLUMBING — RDD 70 GAS PIPE
�mS7 'is in Bill rumcan I a tell.
,z¢ License Class Lic.M
Xa O Dom Comromnr
w a.G ARCHI'FECI"S DECLARA17ON
C r=h g I understand my plan,shall be used a,public remand,
i S❑O Licenced Pndcs,ionul
c iOWNER-BUILDER DLCIARA'1lON
w I hereby affirm,ha I am cxcmpr from the Contractor's License Law for the
following reason.(Section 7031.5,limine,.and Proresrions CnJe:Airy ciy ur county
5 F e which moluire,a permit to conswev alter,improve.demolish,or repair any swnurc
prior In it,isu...c,aha"'nosthe apphcrm for such lnYntino file a signal'carmen,
that he is lirenad panaanWvhe pm,mon—free Cortrxwrs License Law(Chatter 9 Sy. Ft. Floor Area
(cn,nmeating,an Sectio.,loan of nivixi.n,l of the 13nc,x unI Pr,nearions Codd .
or that he is exempt disci m and the basis for the alleged exemption.Any rinlation
at Section 7131 s by any appli,t I tar a Perml sub,,,,the appeeam to o civil Penalty
nfnot more ban fiwhundred dollars s5an. APN Number up cyType
L a,owner of be proi or my employee,n ith,rage.,a,hurt•nk enmperismion. 3591 1.008. 00
will do the work.and rhe.,mnum is nU1 lure led or eirered for rale(See.7m,
II.inca and 1'rolcssions Cmk:'ne Cottonton's Lfaenw Law does not apply man Required Ins ections
w rofpm„erlyWhobuild,orimprove,,naso,andwhodim%suchworkhimselr 106 — SEWER & WATER
f through nu own employcea. haildcd That wen isId
not interaw dedcar or
compile ion.the.If,however,the building nr improvementrdof prun x,IJ x;ididnee car of i'02 — UNDERFLOOR PLUMBING
%nmpletinn,ins osc ofbuilder will have the burden nl'pmving Ihm he did stn M1uiIJ or
,prase int prr,n,ae nraam.y 301 — ROUGH pLUMRING
❑1,;is owaerofthe pmpeny,an,exdrsmelycontracting with licensed rommut 302 — TUB & OR SHOWER
instruct the pmjed(See,7194,Business and Pmres,on,C,xlo:l'I he Cnn(maor'x
i
License Law does not apply to (miner perry an ofpmwho builds or improver tnerenn. 502 — FINAL PLUMBING ENERGY
and who contract,ha such projects with a enntmcons) licensed parsulia In(M 506 — GAS TEST
Contractor',Licence Law.
0 am exempt ndet See. Date B.&P[C for hlti.ma,on 507 — FINAL PLUMBING
Uwnrr y p s
WORKER'SER'S COMPENSATION ii All N
I hercbY ellimt ands penalty nfperjury one of the following J«laraions:
1 • I have and will maintain r Certificam of Consent In alGinsum for Worker's
mpcus;tkn, is pnvided lin by Section 3710 of the Ltm, Curc. Iia the
:rimmrnce of the roti lin xhieh this permit is issued.
1 have and will maintain Worker's Cnn,,itsetiun Insurance,a,required by Scours
9701 0 the labor Coda for the prhnm:vme nt the and far which this perm![is
issued.My kbder'.,Compensation la,mance carver and Policy nontber are.
Car,,: Pd icy No.:
CE RI IPICAT[ON 01:EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
Olt,action ,,,it nor be cmnpleted if me Mmool is fiir ane hundred tollan
ISI(Xp or lcsc)
1 certify that in the pebranu ace of the work lin which this permit is issued,I
shall bol ehnpinY any penmr hit any manner sit an to ne,ona,a ahr,r,the worker,'
Contpcnratinn Laws of California.Date
Applicant
NmICE TO APPLICANT,If.after making this Cenihcae of Iixemption,you should
M:anne subject or Ibe Wmkor's Contpcnsuf inn provisions of(h„Labor CnJe,you nu.st
p forthwith comply with such provisions or this permit shall Mdoontrd revoked.
L
F ti CONSTRUCTION LENDING AGPNCY
a 7 hereby which the,there is a ro ted(Ston Icnding s.Cney for the perinnnuna
Lethe work mor which this permit is issued[Sec}(:97.Civ.C.)
6. ❑ Lender',,Nunn
7 1<mkr'r Address,
U 1 mildly that 1 have mad thin application and slam that the aN,ve intimation is
4zs [.. corset.1 surer to Comply who all city tod county ordinance.and%um laws relating
Q U to Fit ld conswction.and hereby authorize representatives of this city In corer rpm
14the;iht,%c.mendoned pmpcny for inspection pnrpo,es.
6. (We)a8me ms ave indemnily and keep lm...dc,%the City nt C'uperim)ngain.a
p) liubilhicr,judgments,cone and expenses which may in any wary revive against said
U J City in am.equcnce of the granting of thin senior(.
\ APPLICANr UNDERSTANDS AND WILL COMPLY WITH ALI,NON�POINI S'S
VD Date O D�
SOURCE R[/GUlJn'[I sINS- s ( I n !t n�VD y'
siga,ure, ppLl loanl2onvu`T ,4LV y16'UVahe✓ Re-rootti -
❑AIARDOUS MATERIAIS DISCLOSURE
Will the apphcam or nnnm budding-eapant nlom or hurdle hamnloo,hnmerhJ Type of Roof
a,defined by lac Cupcnino Municipal CnJe.Chapter 9.13,and the I Icahh and Safcty
Calaa2552553260?oyes \No Y°• All roofs shall be inspected prior to any roofing material being installed.
Will hert,Sicard,,boom huklinga'eapamawvilm,nmealordesseeswhich If a roof is installed without first obtaining an inspection, 1 agree to remove
mil La...do.,mo,enuahnto I a,defined by the Bay Anv Aa Quality Man:..cmem
until
all new materials for inspection. Applicant understands and will comply with
b Yes No all non-point source regulations.
I hove read'he h;vwdom hone,has regtammcnb ender Chupkr fi 45 of the
alifnmin Health 5 Safety Ctxle.Sections 25505.255}}and 8534.1 ondcnwnd that
I the hntldi ng dos not aarrcatly have a wean(.I on it is my respumibi l try to notify rhe
overprint of the requirements x Inch must le met prior m issuance of a Cer iticam of
Occupuhhn
I\- / Signature of Applicant Date
Gamer in hera,.ed,gent Dale All roof coverings to be Class "B"or better
OFFICE