04060249 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
COlV TttACTbR INFORMATION -
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BUILDING ADDRESS: .;BRGGK WY PERMIT NO.
' ATLANTA CONSTRUCTION INC 040602.49
OWNER'S NAME: MRMITISUEDATH
RT-TTMM-TqWANC- L RI-WEN I-T.N 342 DAISY DR.5
NE: SANITARY �AtOL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
pp o 0 0 0
+lpp LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 hereby arfirse Nn I to licensed under provision of Chapter 9(commercial p
z with Section700/)of Division]of Ne Business and Prefeati...COM,andmyliemseu
A< in full farce and.fleet.
'i Lt.,..Cms LIc.« SFDWL-ONE STORY LIVING 3 , 457
^g D'm
ARCHITECTS DECLARATION GARAGE 484 SQ. FT.
�i I undersand my plans shell he used as public records
30� Licensed Professional
a'p3OWNER-BUILDER DECLARATION
q I hereby affirm that I am exempt from the Convectors License Law for the
—❑D following reason.(SeNun 7031.5,Business and Profession Code:My city at county
$ which requires a permit to construct,alter.improve.dmalreh,or repair try Simon,
prior to is iesume...1sS require the spit icant for such Permit to file a signed wtement
that he is licensed pursuant In the,prevision of the Convector's License Law(Chapter 9 Sq.FI. Floor Area Va t
3 (commencing with Section 7")ofDivision]orthe Business and Professions Code)or 5.x°8000
that he is exempt therefrom and the buss for that alleged exemption.Any violation of
Section 7031.5 by Say applicant for a permit subjects that applicant to a civil Penalty of APN Number Occupancy Type
.at more than Five hundred dollen
❑ L as owner of the property,or my employees with wages u their mice compenretlon, 36922042 . 00
will MNerbac,Cde:;.Corefsnor's Liam
70 M,Bunuof wired Ins ections
and Professions COM:The Cantractah License Law don not hims lf an owner of ry"T p
ownpropemployny b,provirid thavas t Such
ohs tore
ctende oraffemNrosaI his Ifojr_ LE®
own employee,provided that such imphawments ere not intended moRemA tarsale If,
builder the building a,improvementowmenlis llhathwithin arcynr ofrnmplefarrheowner-
builder will leave the Wrdcn of proving that he did not build or improve for pugbxe of
sal" . ,1
g I,uw
an,of the property. exclusively convening with licensed corvb
acrb m f•s g�V /8 1{1415 -
mnstnm Ne project(Sec.7W,Business and Preferences Code:)The COm actor!Li-
comewho contracts Law doss oat apply to est owner of propenY who Wolds or ant tovm thereon,red, lar���
who.Lfor such projects wiNaconvaemrW licensed pursuant INC Convmtora l�F}I„�� �s«�
Liana taw. 01!liy( G
❑Ian exempt under Sec. ,B&PCfar ore
weer ` a¢
ARK 'S MPENSA NCI.ARATON
I hereby ME.under penalty of perjury one of Ne following dcelmatimue
w and will mdmain a Cunifiem of Cement to relr-Insure far Workers Camper.
an,u provided(m by Section 37W of the Leber Code,far Ne perfi tmsrcc of the
work far which this permit Is issued.
❑I haw and will maintain Worker's Compensation Insurance,u required by Section
J7W of 0te labor Code.for the
perfarmmce of da work for which Nis permit is Issued,
My Workers Compeuadan Inunnce carrier and Policy number are:
Carrier, Polley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE
(This Section need amt W completed if the permit is raranc hundred dollen($100)
or less.)
I anify that in the perfmmena of the work far which this pmmit Is issued.I shell but
employ any parson in any mannorso as to Income subject o the,Warken'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,afbr making Nu Certificate of Exemption,you Should
become object to Ne Worker's Compensation provisions or the labor Cuda,you must
Z forthwith comply with such provisions or Nis Permit hort W damned revoked.
CONSTRUCTION LENDING AGENCY
[-+ Ihereby affirm Net Nero is.conwctinn lending agency far Ne perrurmmcs of
a > he.,it for which this permit is earned IS.,307,Civ.C.)
91.
Q Iandc',Name
},z Landers Add.
U O I anify that I haw red Shia application and aum that the Shaw Inromation i,
II. (, council.I agra to comply with all city and county antimatter and sea laws relating an
OV building construction.and hereby audience representatives;of Nb em
is city er upon doe
U above-mentioned property for inspection purposes.
(We)agree m...Indemnify and keep harmless the City of Cupenina again
N liabilities,judgments.casts and expense which may In my way Scene,against sold City
f 3'Z in consequence of the granting of this permit.
^ APP CANT UNDERSTA AND WILL COMM LTH ALL NO P01 Issued by:9 Date
S RC U ATIONS, t
Re-roofs
a fApPlicanu mmnbr D' Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will t applicant ar fMuni building occupant r9.1 or handle HeaAoe mamrial
u MfinId by de Cupertino Municipal COM.Chapter 9.11,and the Health and Safely
Crile.Section 95532(.)7 All roofs shall be inspected prior to any roofing material being installed.
[I yes )AN.
Wall the applicant or rawre building aaa and e equipment If a roof is installed without first obtaining an inspection,I agree to remove
Pp g p 4 ipment or Mriaa which
,.ad..,Sir conaminmts u&fined by Nw Bay Area Air Quality Management all new materials for inspection.
i �,a
❑Yes WNo
I have mad be buand.,materials requiremc asunder Chapmr6.95ofthe Califon
n{a HnIN&Safctyced -bxaMM5,95533an 34.l understand that!fine Wilding
cuncntry new.ren 4 that it ss my ihilily,to notify the,axu sur of der
re m whmaatW ci and a f.cespdix.moroacup Signature ofApplicanr Date
own mthmind agent V All roof coverings to be Class"B" or better