03100203 (4) CITY OF CUPERTINO
BUILDING DIVISION PERMIT 'COO NTRACTOR4 ORMATION:
4te11111 4, .
BUILDING ADDRESS: BAY CONSTRUCTION CO PERMIT NO.03100203
2175 VIA CAMINO CT
ER'S NAME: 924 KENNETH AVE PERMITLSSUEDATE
t.,SHOK AGARWAL 10/29/2003
PHONE: (408) 590-4263 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
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0ELECT PLUMB MECH
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�Op LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
with Sondra 7000) f Division 3 atom Businessland Professions Code,and my license is
iofuumneand effect. EXTEND (E) DECK & CONVERT TO STORAGE
a,�Z License Class Limit
Ech,❑ Dem T'SContractorFINALEO
g ARCHITECTS DECLARATION
�a I understand my plans shall M used as puhlic records
)yU
°on LicenudPmfcssional JAN 1 3 2004
S OWNER BUILDER DECLARATION
' 1 hereby affirm then 1 ora exempt from the Contractor's License Law for the ,
O 0 O following mason.(Section](131.5.Business and Profcssiens Code:Any city m county
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2 ff which requires a permit In emournn,alter,improve,demolish,or repair any structure RIMMING 5 O O 0
Azi priorto its issuance.also requires the applicant for such permit to file a signed statement
sp that he is licensed pursuammthe provisions ofthe CommemrsLicense aw(Chapter 9 Sq.Ft. Floor Area Valuation
5t- (commencing with Section 7")of Division 3 of the Business end Professions Coda)or
that he is exempt therefrom and the basis for the alleged ammption.Any violation of 32646012 . 00
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of APN Number Occupancy e
not more Nan five hundred dollars(.9503). P Y EYP
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do to work,and the normal.isnot intended or offered for sale(Sar.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of Required Inspections
property who builds orimproves thereon,and who doessuch work himself Or through his
own employees,provided that such improvements are not intended proffered for aide.IT,
however,Ne building or improvement is said within can year of completion,Be owner-
builder will have the burden of proving Nat be did not Wild or improve for purpose of
sale.).
h as owner of to property,am exclusively contracting with licensed contractors to
onstmct the pmjen(Sec.7W,Business and Professions Code:)The Contractor's Li. _
cane law does not apply to an owner of progeny who Wilds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pumuant to the Convector's
License Law. '
❑tem exam un rSe ,B&P C for this reason
Date
/
WORKERS 'N N
Y Ihemby affirm under pcnalt o perjury one of the following declarations.
❑than and will maintain a Certificate of Consent to self-insure for WorkerRCompen-
antion,as provided for by Section 3700 Of Ne labor Code.for the performance of the
work(or which this pennil is issued.
❑1 have and will maintain Worker's Compensation Insurance,as requited by Section
3700 of the Labor Code,for the performance of Be work for which this permit is issued. -
My Worker's Compensation Insurance carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be completed Bthe permit is for one hundred dollars p$BXB
nr lcsaJ
1 certify Out in the perfm none.Of the work for which this permit is issued.I shell at
employ any person in any manner so as to become subject°the Workeri Compensation
Iowa of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker'Composition provisions of the Labor Code,you must
0 forthwith comply with such provisions or this Permit shall he deemed revoked.
ti y CONSTRUCTION LENDING AGENCY
1 herchy affirm Nat there is a c.M.I.Eon[.note,agency Inr the Berfurmance of
Ya 7 the..,it for which this permit is dssucd(Sec.3(197,Civ.C.)
A Lender's Name
z Lender's Address
Q 1 certify that 1 have read this application and seem that the above information is
y correct,1 agree to comply with all city and county ordinances and state laws relating to
�YJ building construction,and hereby authmia representatives of this city to cnmrupon the
ahovcies judgment,
PmPcrsi for inspersion Purposes.
ti (we)agree to save,indemnify and keep harmless the City of Cupertino against
N
liabilitiesquence of
grand ng A.pof this
esmitch mayin any way come againstsaid City /� a
J� in consequence of the greening of this Permit (/
APPLICANT UNDERSTANDS AND WILL MPLY WITH ALL NON-POINT Issued by: Date
SOUR RE ULA ON 1 n tl
'7 Re-roofs
St a of ApPlicanUCOn Dem
HAZAR S MATERIALS DISCLOSURE Type of Roof
Will theaPplicanlerfut building Occupant store or handle haosundOus material
I Bond by he Cupertino Municipal Code,Chapmr 9.12,and the Hcalth and Safety
�h0n 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Vca �Ne
Will the applicant or future building occupant tau equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
'I emit harardnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? y�
❑Yes gt4n
I have mad the hanolm smaamrials myuimments under Chapmr6.95 ofmc Califort
ria Hoalth&Safety Cmik,Sectium 25505,25533 and 25534.1 understand Nat if the building
dos not A� 1�:an a tenant, mit is my respons' 'lilymnoulyNescuPanwfthe
requircmoat n 'pose issoancc cr ntficam of Od�iZy ) Signature Of Applicant Date
91 0
OvM gent Da All roof coverings to be Class "B"or better
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