04030203 (2) CITY OF CUPERTINO '>`""`_°
BUILDING DIVISION PERMIT #CONTR'ACTORINk'.,ORMyATI,ONa: d
BUILDING ADDRESS: PERMIT No.
TERRY BROWN, GEN CONTRACTORo403O2O3
RT TTO RD LL= 21
R'S NAME: PERMIT ISSUE DATE
1W AMAR GUPJA 1A510 laic, RARTDT ;441: -nn Ion /2
PHONE: SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
uo0 LICENSED CONIBACfOR'S DECLARATION
fiI hereby affirm Nal l Am liccnmd under pmvisiou of Chapter 9(commencing Job Description
with Section TOM)of Division 3 of the Business and profesions Code,and my license is �-
^�,,, in full fine.md effect. I
5q? License Class Lica REVISIO -PIERS
�-o mm cAnuaemr PERMIT ISSUED/ORIG. #03080119
Q�qsy ARCHnF.CTS DECLARATION
I uedcmund my plana shall M it As public mmrds
�yU
;oG Licensed Pmfcssinnel
3 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am azempt from de Convamo's License law for the
o o following=am .(Suction 703 1.3,Business and Pmf issiuos Code:Any city or county
x$ff which require A permit m construct,alter.improve,demolish.or rtPail any structure
y
,;o prior to its issuance,also requires ted applicant for such Permit to file a signed su¢ment
5- that he is licensed pursuant to the provisions of the ComrscturiLicense Law(Chapmr9 Sq.Ft. Floor Area Valuation o
ai a (commencing with suction?")of Division 3 of the Business and Professions Code)or
i $ Out he As esempt therefrom and the hese for Ne alleged cacreption Any violation of
Section 9031.5 by an,Applicant for A permit subjects Na applicant to A civil pc..try of APN Number Occupancy Type
not mom than five bundled dollars($500).
I,ss owner of the propany,or my cmploycu with wegm ss Heir sole compenssdon, 13719031 . 00
will do Ne work.end On mocwm isnot intended or oRcled for Asia(Sec.?016.Business
and Proicanoe Cade:The Contractors License Law does not apply to an owner of Required Inspections
propenywho Wilds or improve Nkscon,and whodoessuch work himulfor through his
own employees,providca Nat such improvements are notinetWcd oroRered far sale.If.
however,Ne Wilding or improvement is mid within one year of compusion.the owner-
builder will hove the burden of proving Nat W did not Wild or improv for puryose of
sale)
❑1,As owner of On property.Am ezcleivcly contracting with licemed convectors m
contract Ne pmjcn(See.)Ossa.Business and Professions Code:)The Conuectofs Li-
came law docs not apply m an owner ofnmpeny w'ho builds or improves Neuron.and \ !�
who conflicts for such Projects with acontra lor(s)licensed national in the Contractors v
License law.
❑I am exempt Araks See ,B&P C for Nis memo
el Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury arc of Ne following doclarations:
❑1 how And will maintain a Clutdricad,of Consent to self-toutic for Workers Cortina-
smon,As provided for by Section 37M of the Lather Code,for the performanm of Ne
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,As acquired by section
37OO of Oc tabor Code,for On pldiOn ame of Na work far which Nis Permit is issued.
My Workces Compensation Wallace,carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This action recd ort he completed if the Permit 1,rnranc handled dollars(SIM)
nr ass.)
I unify Nat in the puff rreanm of Be work for which this Permit is issued,1 shall not rt,
employ any perm.many manner of as or become mbject to On Workeri Compensation
laws of California.Date
Applicam f,
NOTICE TO APPLICANT:If.after making Nis omiEcam of Eaamption,you mmW
Income subject to Be Worker's ComPetwtion provisions of the lade Code,you muse
ZZ forthwith comply with such provisions or this Permit shall be deemed rookd
ej�1
.�.. CONSTRUCTION LENDING AGENCY
�1 IVJ
I-+ I for which
Ne thcrc isaconstmc.3M.. agency[or Nc performance of �"
1' use work for which Nis permit is issued(sec.7091,Co.Civ.C.)
W W Icndcr'stheme p,(�
D. Lcndcr's Address
U 0 1 cenlfy Nu I have it Nu application and sum Nat Be about information is
W r colonel.1 agree in comply with all city and county on inances and sum laws relating to
O V building construction.and hereby aUO06M mposenudwaS of Nis city to enter upon Be
�ftl shove mentioned property for inspection purposes.
(We)again of saw,indemnify and keep hezmless Ne City of Cupertino against
F H Oabilides,judgmcns.eosts and expenses which may in my way accrue againot said City
V Z to consequence of On granting of this Permit.
'-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTI sued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicanUConData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the a Cupaal or future building e,Chant morn or handle Health and
deIncl io the 32(a)?ns.Municipal Code.Chapter 9.13, ,Ilk Health and Safety
c,Section 25533(x)? All roofs shall be inspected prior to an roofing material beim installed.
❑Ye ON. P P � Y g g
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 hazardous air comaminaou As dcMcd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes 0 N
than mad Neh 7aNwsmammalsmquimmcnuundcrChapmr6.95of Nc Califon
Aw Hwhh&SafelyCole,Scctlmu25N15,25533and25536.1 anacrsund NmiHhe Wilding
deet not cuncndy haw A tenant,Nat it H my respoeihibly m noddy im aeu,.l of the
requirements which must be met plot o issuance of A Certificate of Occupancy. SI¢naw-re-of Applicant Date
Owner or authorized.,at Date All roof coverings to be Class"B"or better
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR-INFORMATION
BUILDING ADDRESS: AMAR GUPTA \ PMIT
N 0 0119
I:R'S NAME: PERM UE DATE UI/
AMAR GU
PHONE: SANITARY OL N0.
ARCHITECTrENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
n00 LICENSED CONTRACTOR'S DECLARATION Job Description
YmF I Wroby affirm that I am licensed ands,provision of Chapter 9(commencing
<Z ty with Section 7")of Division 3 of the Busnus and Profcssiuv Code,and my recuse is
imfall force andeffel. NEW 2 STORY SINGLE FAMILY DWELLING
5 Z License Class Lic.N
SFO Date Cmuaclr r_. LIVING SPACE 9435 SQ. FT. /GARAGE 528 SQ. FT.
ARCHITECTS DECLARATION
i -a I cWcstand my plans Naii W used vpuhit-records (INCLUDING BASEMENT 3500 SQ. FT. )
H
3017 Licensed Professional
3 OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt fru.the CrOo. n's License Law for the
Oo following mason.(Section 7031.5.Bulinusand ProfCcoms Cole:Any city vcounty
K: which requires a permit to contract,alter,improve.connoUsh.or repair any structure
poor m its hatumcs.also m toms the applicant for such permit to flit a signed statement
< thatheislicensedpursuan0otheprovisipvofthcContractoriLicenselaw(Chapter9 Sq.FL Floor Area Valuation
(commencing with Section 7")of Division 3 of the Business and Professions Code)or nnnnn
i $ Chat he k exempt tocrefrom and the bssu for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars($500).
D 1,u owner of the pmPeny,m my employees with wages as their mk compensation,
will do the work.and Ne structure is not intended of offered for ale Sec.7061,Business 1 0(]
and Profession Codd:The om amoYs Lt.=Law doesao,apply m an owner of Required Inspections
progeny who builds or improves thamon,and who dOessuch work himulf or through his
own employees,provided that such improvements arc not intended.offend forsale,if,
however,the building or improvement is mid within one yor of completion,the owner.
builder wia have the burden of proving that ac did not Wild or improve for pool.of
axle.).
D 1,as owner of the propenyl am exclusively contracting with licensed contractors to
comwct the project(Sec.7060.Business and Professions Code:)The Contractor's Li-
cove Law dos not apply as an owner of propeny who builds or improvs thereon,and
who contracts for such projects wit a eontracmr(s)licensed pursuant to do Commences
License Law.
❑1 am exempt under Sec. .B&P C for this mason
Date
WORKER'S COMPENSATION DECLARATION
1 hereby afftmt under penalty of perjury one of the following declarations:
730110
have and will maintain aCertificamofConsent ComiGinsure for WartrriCompen-
n,u provided for by Section 3700 of the Labor Code.for the performance of the
for which Of,permit is issued.
have and will maintain Worker's Compensation Ivu mance,av mquired by Section
of Ne Labor Code,for the performance of the work for which this permit is issued.
Wnrimes Compcvation I...earner and Poli,number art:
Canner. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sestina need trot M Completed little permit is(attune handled dollars(SIM)
or los.)
I cenity 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 Worke 'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Cenircam of Eaereption,you should
become subject m the Workera Caps adoon provisions of Ne Labor Code,you must
.JO forthwith comply with such proyisios or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
'r. 1 hereby alfum Nat do.iv C.Orman inn lending.;on,for IM perfumurue of
a the work for which this permit is issued(Sec.3M7,Civ.C.)
10 Lsndcr's Namc
Z LcnCdr's Address
U 0 1 canify,Nn I have read this application and cute that the above mea m aiun is
W P correct.I ogre to comply with all city and county ordinances and state laws misting to
0 U building canmuction,and hereby amoodm mpressnUiivss of this city to cater upon the
} a above-mentioned property for ivpeetion purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
FN liabilitis.judgmand,costs and expenses which may in any way accrue against said City
C.)z his Permit.
APPCANTUNDERSTANDS
cof the grounaing,of t
LAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR GULATION
3-Z3-oy Re-roofs
Signature of Applicart/Contractor Data
--''HAZARDOUS MATERIALS DISCLOSURE Type of Roofmu
Will the applicant or future building Occupant slam or handle hdous material
dchncd by the Cupenino Municipal Code.Chapter 9.12.cede the Health and Safety
s.Sceden 255324)? All roofs shall be inspected prior to any roofing material being installed.
Dyes *Nu
Will the applicant or future building occupant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hmardnus air emoo m mans as aflocd by the Bay Arta Air Quality Management all new materials for inspection.
Distric?
DY.
1havemaltheh za ousmaterialsmquimmenuunder Chapwr695of Oc Califon
does not
Code,Scetiovhat iii my responait36.1 undersuM thac upanthe Of
tics oat curtcndy have a tenm4 that it u my mspomibility m redly the a<upent of Nc
requi n whichmtrat mdtpnprmissa,necancenireatepracapmmy. Signature-ofApplicantDate
5- 2-3-Uc
Owner or mthomca agent Dam All roof coverings to be Class "B"or better