05070053 (2) FBUIIEDING
TY OF CUPERTINO
BUILDING DIVISION PERMIT Ue
ICON RACT�()RINFORM=ATIOIV "'''.,
0883 ELEND ADDRESS: STEVE NAN CONSTRUCTION PERMIT N°.05070053
ER'S NAME: PERMIT ISSUE DATE
GOVINDARAJ PADMANABAN 919 L
E: SANITARY NO. CONTROL NO.
(408) 203-3933
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
IOo LICENSED CONTRACTOR'S DECLARATION Job Description
C 1 berebffi
y arm IiavNrc
Nal 1 am Mas provisions of Chapter (mmmcevrit P
U
won section 7")of Division 3 of the Business and Professions Code,AM MY license is
"�' mmnrnm and err L ^� REVISION--FAM. RM DOOR/MS BED/HALL BATH
p�? License Class' S/� Lac.M 7� �� .
Dal C.Mmcum NO NEW PERMIT ISSUED�ORIG. #05020148
ARCHITECTS DECLARATION
as I understood my plans shall he used a public records
>toU
g GG Licensed Professional
3 OWNER-BUILDER DECLARATION
I hereby affirm Na I am exempt from the ChnmClara License Law far the
p O following mason.(Section 703 1.5,Business and Professions Core:Any City or county
<$fa which rt9uires a permit to ennstruct,ober,improve,demolish,m reFail any strucwm
poor ser its issuance.also requires the applicant for such permit to hie a signed statement
s<
that hculicensed putmnmrodue pro visionsoftheContractohLicense aw(Chapte,9 Sq. Ft. Floor Area Motion 0
YFC (commencing with Section 7000)of Division J of the Business and Professions Cole)or
y that he is exempt IMmfmm and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjecu the applicant to a civil penalty of APN Number Occupancy Type
not mom than eve hundred Callan($500). 32630025 . 0 0
❑1.u hewer of the Property,or my employees with wag=u their sole compevdeces �']-
aindotbcwmk,andthe e:The Curt is pori Licenterockti Lawddfmml apply ad an Buunm Required Inspections
and Professions Code:The wsde ton.and
Law doh not apply if rt owner of q P
pro fcny who b,prsorim(rods,Thereon,and who Am not intended
m ffemdcifor through his
owncmflam Wil iaz or erpoBud sochimprovem within
am
for sale.if. �/
howenc, orhnfmvcmenlg sold eithinone year of Completion.pu owner- /
Wilder will base the Widen of proving Wt he rid not Wild of improsm fm Purpose of �
solei.
❑1,as owner of 0¢property,am=elusively contracting with licensed consocwrs to �)
commict the project(Sec.70x4,Business and Professions Cade:)The Conuanar's Li-
come Law does not apply As an owner of propeny who Wilds or Marrows Bureau.and.
who contracts for such pmjecu with a co memr(s)licensed pursuant an,the Comuacwra
Liccnm Taw.
❑1 am exempt under Sec. .B&P C for this rtsson
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under faintly of perjury one of the following declarations:
(�^ Iban and will mvntain a Cmtifcare ofContentwselM1insumrmWorkersCompen-
sation,es provided far by Smuon 3700 of dm Laber Code,for Ne perfmmanw of the
work for which this permit is issued. .
❑I have and will maintain Worker's Compnuation Insurance,as required by Section
7]00 of the labor Code.for the performance of the wvrk for which this permit is issued.
My Worker,Compensa' Insurance Carni end Policy number art:
Cents . Policy No.:
CERTIFICATE OF EX W.4PTION FROM WORKERS'
COMPENSATION INSURANCE
(This secunn nem net bccomplmed irtbe Minor is ran one hundred dollars($100)
or less.)
I anify that in Be Performance of the work for which this permit is issued.I shall not
employ any person in any manner m As an become subject o the Workers Compewuuon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:.If,after making this Cenifcate of Exemption,you should
became subject in the Worker's Compensation provisions of the labra Code,you most
w,O foMwidt comply with such provisions of this permit shall be instead revnlam.
Z= CONSTRUCTION LENDING AGENCY
[-d Iherehy affirm that there is a construction lending agency for the performance of
Cthe work for which this permit is issued(Sec.JW7,Civ.C.)
Ir.1 0 tondos Name
0. Under's Address
U 0 1 athfy that 1 have read this application and state that the above information is
Ls. E^ com;eL I agree to comply with all city and county ordinances and sum laws mlating to
OU Wilding cmmtmction.and hereby authoriae rtpr=cnuums of this city to enter drum the
r LU above-mcnuoned prorcny for inspection pur)nsea
G (We)agree to save,indemnify and keep harmless IW City of Cupertino against
N liabiliue;judgmenu.casu and eapensh wM1ich meyman we ac cmc apainstsaid City
U z h consequence of the granting hf this permit
^+ APPLICANT UNDERSTANDS ND WILD PLY WITH ALL NON-POINT Issued by: Date
SOURCE REG
TIONS. p.�•_�f''
T O 1 Re-roofs
/ �CSigmrufeorApplicanucim_HAZARD0USMATERIAISDISCLOSURE
°ate 'Type of Roof
W II rte ap'EcMu orfutureWilding occupant store or handle ha=rdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.semen Yes �zsvzan, /�Na All roofs shall be inspected prior to any roofing material being installed.
r a If a roof is installed without first obtaining an inspection,I agree to remove
J Will the applicant or fuwm Wilding meueaB us,equipmentAir cal or devices which
mit District? us air contaminants ss defined by the Bay Arca Air Quality Management all new materials for inspection.
District? s
❑Yes No
I have mad the h=ardmsa materials mquimmenu under Chapter 6.95 of the Califon
nia Health&Safely Code,Seeuons 25505,25533 aud 8574.1 understand that if tW Wilding
does out currently how a mnan nsi
L that II is my���aaaspohility b notify the occupant of the
mquimmcnu w�M.M W poor u1 issd5nce or a Cmifeate of Oce Y Signature of Applicant Date
Owner or
ulM1oornJ agc-"—�'nDau
�-`— All roof coverings to be Class"B"or better
a