05100090 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMITlµ�LuR.4,,,CT.QR
BUILDING ADDRESS: PERMIT N0.0 510 0 0 9 0
858 E ESTATES DR
ERS NAME: FERhff(ISSUE DAM
ERS
GERARD' PALLIPURAM
MTONE: SANITARY NO. CONTROL NO.
ARCHITEC fiENGINEER: BLDO BUILDING PERMIT INFO
ELECr PLUMB MECH
iOp LICENSED CONTRACTORS DECLARATION Job Description
1 hereby affirm than 1 m licensed under provkimu of Chapter 9(mmmenmp P
with Section 7000)O Division 3 of the Business and Prefutamen Code.and my license I.
In full ram.adnnem. CERTIFY (E) ADD ON LIVING ROOM
z Licenau Lima Lk:.
�' Dam Contractor REPLACE ROOF W/COMP SHINGLES
3 ARCHITECT'S DECLARATION '
I understood my plana sWI be used as public rased,
�dU
yard Licensed Pmfeuimal
m OWNER-BUILDER DECLARATION
i I hereby art,.thin I am exempt from die Canuactors License Law for the
p o following rcuoa(Section 7031.5,summers and Professions Cade:My city Or county
59 an which require a permit in congruq alone.Improve.demolish, re an repair my structu
-Zi prior m its issuance.aha requires ft pt for such permit to rile.signed 0aemem
G
that bulslkensedpursuant mthepmviI=orthe comacm/sLamemLaw(Chaptm9 Sq.Ft. Floor Area Valuation
(commend'with SINN 7000)of Division 3 of the Salomon and Prareuion.Cade)err $99606
$ dont he is eumpt therofrmn and de bask for the alleged eaempllom Any violating of
SeNN 7031.5 by any applicant far.permit subjects the applicant to a civil penally of APN Number Occupancy Type
not mom Nan fiw hundred dollars($300).
❑1,as owner of the property,army employe.with wages as thehmlemmpeuadon.
All
will do the work and the structure knot lnrendedor offered far am(Sec.7044.Business res,. {y
and envy who
Cade:The Cont emon,License IoW tiros WE appy lf rt owner of _ RegUlTefl•spSp ons
propmy wW b,9m mfmprma therms antlwW da.wNwarkhim ffued rough his V�OOjiYJ Py���v'y
pwn war.mopth m,progded prove lm Is mid whom
ne yew
maedim.Russia.s,
Wildathe Wildingoringowmmtkheldwithinme year afmmpledN,theposer•
Wild.NB have the buNm of proving th.l K did set build air improve far purpose of � ✓,y�V
ask.)J Y
Ions..Ownsr of the property.,B inclusively and eNuasdng with )This Cmmramm m
room
the project(Smapply
no gree Business and Praftsetinyvhaons Codc)The se;theme.
n 00
mw law do.not apply m ia with
a of icammywho Wilda Or impmwa theuan,and
went contracts for such project with a mntrwaMU Ikanadpunuam as the CNummr's
LiceLaw. y
I.
.empt _.Bd:PCf Ns wages Ay
Due I tl
S COMPENSATION DECLARATION
I hereby 27mr penalty of perjury arc of the following declarations:
1haw404WBImainuinaCe BMWofCOWntWUlf-inose(or Worth Compere
same..provided for by Sedan 3700 of de,Labs Cdc for dm perfarmaun of W
work for which this permit is mud.
❑1 ban and will maintain Worker's Comp gain InNrance,as required by Secdon
3700 of t e labor Cada far the performance or the work forwhich this permit k legend,
My Workers Comragammn lmmranm carries ad Policy number are: ,
Carder. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This mcdca need not bu completed little permit is faresuhunNd doom($100)
or loss)
I unify Wt In the performance of the ooh for which thin permit is issued.I shall am
Omitanyp..O, Y IIWN mppo�wsebjeet retie Warteri Campewdan
Laws of Caiifpmia
Applleml
NOTICE TO APPLI afar making this Certifi.e of Exemption.you should
become subject m in
s CompenUdon provisions of thin Laher Codm you mug
.J O faMwith comply with such providons or this permit Nall be deemed invoked.
z CONSTRUCTION LENDING AGENCY
I hereby affirm them drum is a con.wcdon loading agcwy fur the performance of
DC> the wort fur which this permit Is Wood(Sec.3097,Cie.C) '
OW. Q Lenders None
r7 Z Lenders Adder.
U Q 1 cartify that I haw read this applicdN and sum thin the&bow informadon is
1L ^ come I pee be Comply with all oily Na countryOrdinances Nd sue kWs nlNog m
p rV" building construction.ad booby authorize upmxnutiv.of this city w en=upon the
W aWw-mentioned properly for Wpedan pUrPORL
L1, I%)ague m saw,indemnify and keep harmless the City of Cuperluo'Slim&
fq liabilities,judgments.mom and expensmi which may In my way attTw'Sainst said City
U Z in consequence of the Scandal of this permit, y
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date p- d
SOURCE REGULA ppssi� ,
_��,QW1h� itW D'C� Re-roofs
Signuure of Appli ARD US MATERIALS DISCLOSURE Con Type of Roof
Will zee applicant m future building occupant.score or handle haurdous macerid
u defined by the Cupertino Municipal Code.Cbaper 9.12.and the Heaith and Safety
xenon 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes 911 0
w&II the applicant m future building aaupent We equipment ar dcvima which If a roof is installed without first obtaining an inspection,I agree to remove
emh husumus air mm eninsnu ss deMcd by thin Bay Ata Air Quality Manageeneml all new materials for inspection.
Dimict7
❑Y. 11)Na
1 have mad the hawdassmgerlakrequiremem mater Clupur695ofde CAlifer.
nkN.IthhSaic&yCOde,xNw13303.75377 gW733M.lundwmd thglfthe Wilding
docs not currently haw a t k my mponaihili&y re notify the Occupant or de
rryviremcnu which mu t 'a uanee ofa Certifemor Occup ,/ Signature of Applicant Date
Owner a,mlhariyea a e m. . All roof coverings to be Class"B"or better cv