04040065 (3) CI TY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION A
BUILDING ADDRESS: - MISSION DEVELOPMENT CORP PERMITND.04040065
ER'S NAME: PERMIT ISSUE DATE
PALANIAPPAN KARVP
JNE: SANITARY NO. CONTROL NO.
(510) 657-4777
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
:O o LICENSED CONTRACT'OR'S DECLARATION
1 hereby affirm that 1 am licensed undo provisions of Chapter 9(commencing Job Description
n�y with Scctipn7 qof Division 3ofdte Busi 4 di Pmfcssi d andmylicenscts ��r+iAA���MEM
in full far erma 2 BATHRMS UPGRADE IV
,�Z License Gles Lie.N
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ARCHITECTS DEC RATION
n Dam C _ AUGp ,t
a Iundcr yplansshall W.wdea public records G jJ 009
6
ioN Licensed Professional BUILDING ,
gS OWNER-BUILDER DECLARATION IInnI�IL®�.\�aV
IS 1 hereby affirm that I am exempt from the Contractor's License Law for the B
OO following mason.(Section 7031.5,Business and Professions Code:Any city or county
K m ff which requires a remain m construct,alter,improve,demolish,or repair any structure
`Z" prior to its issuance.also requires ted applicant forsuch permit 1.Men aignedstammenl
Wg i thot heishernscr,mau
nnathepnev,BionsofdvrCmruactm'sLiccn.Law(Chimser9 Sq. Ft. Floor Area Valuation
y m (commencing with Section 7"oo(Divoon Sof the Business and Professions Code)or
i that he is exempt therefrom and the basis for the alleged exemption.Any standon of
Section 7031.5 by any applicant fare Permit subject,Nc.11licrom m a civil Pendry of 3 @aPIb nffi®er 0 0 Occupancy Type
nnamm,hanrwchandomdollma(x50B. P Y YP
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended oroffered for sale(Sec.]094,Business
and Professions Code:The Contractor's License Law does not apply m an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himself orthrough his
own employees,provided that such improvements are not intended molfered formic.If,
however,the building or improvement is sold within one year of completion,me owner.
builder will have Ne burden of proving that he did not Wild or improve for purpose or
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li. _
cense Taw does not apply to an owner of property who Wilds or improves thereon,and
who contracts for such pmjecm with a contractor(s)licensed pursuant to the Contractor'
License Law, ,
❑I am exempt under Sea. .B&P C for this reason
Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of Perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to sel6insure for Worker's Comrmn
..tion,az provided for by Section 3]00 of Ne labor Code,for to performance of the
work for which this Permit is issued.
0'1 have and will maintain Worker's Compensation Insurance,u required by Section
3100 of the bor Code,for Ne performannryycc9eeeeee of the work for which this Permit is issued.
My Work m eemionurand Polic ober are:
came.: %�- Pmi,y
CERTIFICATE OF E%EMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not hecomplemd ifthe Permit is for one hundred dollars(SINE
or less.)
I certify that in the perfamource of the work for which this permit is issued,I shall not
employ any person funny manner so as m We...subject In the Wcow r'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,of ler making this Ccna(wid,of Exemption,you should
become subject to the Worker's Comr,nsetion provisions of the Lahor Code,you must
.JZ forthwith comply with such provisions or this Permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
F-aI hawhy affirm that there is a construction lending agency for the performance of
R'I the work for which this permit Is issued(Sec.3097,CO.C.)
W� Q Lender's NO
a z Lender's Address
U Q 1 certify that 1 have read this application and soot,that Ne above information is
W (✓ correct.I agree to comply with all city and county ordinances and state laws relating to
QU building construction,and hereby apthodae repeacmativcs of this city to enter upon the
W
.1now-mentioned property for inspection purposes.
(we)agree to save,indcmni fy and keep harmlesS the City of Cupertino against
ami Vl liabilities,judgments,costs and expenses which may in any w y accrue against said City
U Z in conseyue the gmrling this permit.
^' APPLIC ND ST AND WILL COMPATH ALL NON-POINT Issued by: Date
SOu Gu 0 r ✓✓✓
01 Re-roofs
Si nature of p ea ntract., .pal
ARDOUS MATERIALS DISCLOSURE Type of Roof
Will cap Iicant or franc building occupant store or handle hasardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
.ode.Section 25532(.)?s All roofs shall be inspected prior to any roofing material being installed.
❑Y,
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
it hazafdous air contaminants as defined by the Bay Area Air Quality Management
stria? all new s for inspection.
IG�'ru
❑Yea
I have reaJth s.1 materia' yvircment,un der Cha Par 6.Y5 of the Cali fit .
ria Heal th&Safe odc,S dons 25NI5. 533 enJ 25534.1 undersand that ifdm huilJing
miss mo c'une havc at' y respdnsibility to nodl'y the occupml of the
requiremen en ri unanceaf.eem0enteorOceni r IgnatureofApplicant Date
Owner r mimd.gen o e All roof coverings to be Class"B" or better