04010001 (3) CITY OF CUPERTINO
BUILDING DIVISION PIT CONTRACTOR INFORMATION
",
EI M
BUIL-DING ADDRESS: RAJEEV & VARSHA JOSHI PERMIT N00401000I
368 CnT,RY All
OWNER'S NAME' PERMrr ISSUE DATE
RAJEEV & VAR
E: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Zia,
hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JollD�escription
wish Section 7000)of Division 3 of the Business and Pofceiva Code.and my license is
in mu rota anatrren. KITCHEN REMODEL ALE�
Eg Z License Class Lie.N
4F m DateContractor
ARCHITECTS DECLARATION APR 7 ZOoA
e a I undcrsunJ my plans shall he used u public records cf
JU,U
C Licensed Professional flan
tn
lTm that
DECLARATION 1%S ��®�(���
4 1 hereby arat I am exempt Gran
um the Cmmors License Law far the LL U Ntl
00 following mason(Secuun 7031.5.Business and Profexxiona Code:Any city or county
K m which requires a Permit to construct,alter,improve,demolish.nr repair any suunure
Ply prior to its Utuonce.also nNuiresthe applicant forsuch permit to file a signeduaLemem
is that he is licensed pursuant o the povisiona of NC Contractors Lisrnm Law(Chapter 9 Sq.Ft. Floor Area Valuation
xt-� (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y - the he is rm.ift two,fmm end the basis for the allcgcd exemption.Any violation of
Section 703 1.5 by any applicant for a permit subjccu the applicant o a civil Penally of 31WN8,D3Mu00 Occupancy T
nm mot than nm hundred don..(S=. P Y YPe
o I.to owner or the Popcny.or my cmploycu with wages as tleir.wle compensation,
will do me work.and the structure is not intended or offered for sale(Sec.700 ,Business
and Professions code:The Conuaeme,Lion¢law doe at appy to an owner of Required Inspections
property who builds or improves thcoeun,and who does such work himself or though his
Own cmploycu.provided that such improvements sure rot intended or offered for sale.If.
however.the building or improvement is mid within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose or
salt.).
1,as owner of the pmlaxri,am exclusively contracting with licensed contractors to
construct the pojecl(Sec.7(3aa,Business and Professions Code:)The Contractor's Li .
cane Law does not apply to oa owner of propcny who builds or improve thereon,and .
who contracts for such p M)".with a cmntvnm(s)licensed pursuant to the Conuacors
Liccom law.
®Iam j^}'y't{un soc. .B&P C for this mann
nwne es l�lf t>S Date 1 .2 ADf9
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declarations:
I have and will maintain a Cenificate orcoreent to elf-imam rorwurkerscumpen-
satimn,a povided for by Section 3700 of the Labor Code.for the performance of out
work for which this Permit is ieucd.
❑L have and will maintain Wmkcri Compensation Insurance.a required by Section
3700 of the Labor Cod.,fm the por tmerrnce of the work nor which this permit is issued.
My Worker's Com tanamion Insuance prier and Policy number are:
Camcr: Policy No.: _
CERTIFICATE OF EKEM MON FROM WORKERS'
COMPENSATION INSURANCE
(This uctinn need not becomplewd if the permit is formic hundred dollars(SIQq)
less.)
1 certify Urn in the performance of the work for which this Permit is issued.I shop not
employ any person in any manner so IN to become subject o the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:if,after making this Cenificae of Exemption,you should
become subject to the Worker's Comptwtion provisions or the labor Code,you muss
.J z forthwith cram ply with such provisions or this Permit shall M deemed mwiked.
z'O CONSTRUCTION LENDING AGENCY
'pw�.. I bachy affirm that there is a coatoction lending a6ene,rot the Performance of
!X the work fur which this permit lammed(Sec.3(N7,Civ.C.)
lt7 Lender's Name
5'
Uz Umder's Add.
V P 1 cerree than 1 have read this application and state thn the marathovel information mtatimn is
tL F., bonen.lagreeocomply
and with all city and county oNinencesand Cute lawsrelIongo - -
QU building cotuwetion,any hereby aumonpr mpresematims orthisCity menterupon the
} liaoacros,judgdPoleny for inspection whichsca
(Win)agree m save.indemnify and tinct,harmless the City of Cupertino against
rZ incoisequnceofte'mo�ing.1 pis primbichmay inany way accrue againsLsaid City ��
V z APPLICANTeUNDERSTANDSnoting.1 tAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCr�Gtp LATIONS.
Fe(0Sl4 �a j°0y Re-roofs
sJgpammc of APpncanVCommbor L are Type of Roof
HAZARDOUS MATERIALS DISCLOSURE yp
Will the applicant or future building occupant store or handle harudous material
a defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532N)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes P.
Will me applicant or future building Occupant use cgoiPmenL ver devims which If a roof is installed without first obtaining an inspection,I agree to remove
it hacardous air contaminants as dclined by the Bay Arca Air Quality Management
mi"? all new materials for inspection.
❑Yes dNO
I have read me haaardouur materials requirements under Chapter 6.95 of the Califor-
IdWr;
Hc.lth&Sof�y Code.Secdoa 25505.25533 MU25534.I undersand the ifft bumdlmg
is
r
not cuemly have a tenant.that it u my responsibility to nobly the Occupant of de
wimmeaytyaw-hibhmustbeme(priora.ismiseeor.CerdOcaemraeuprney. Signature of Applicant Date
O cr mrsauthmrimd agent�er K..IDSoa,� 1/s/zeD1- All roof.coverings to be Class"B" or better