07070126 CITY OF CUPERTINO
BUILDING DIVISION
PERMIT
BUILDING ADDRESS: PERMIT NO.
20685 ACADIA CT TBD - TO BE DETERMINED _ 107070126
0 W NER'S NAME: PERMIT ISSUE DATE
KANDATHIL THOMAS P AND IVY P 107/'16/2007
NtE't SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: I 1 BUILDING PERMIT INFO
BLDG EL PLUMB M
O 6 LICENSED CONTRACTORS DECLARATION � O
V p I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
jZWU with Section ndefec Division 3of the Business an ProtessiunCode,andmylicenseis REPLACE (E) FURNACE & WEBER HEATER ADD A/C.
H in full force and cffec� j A 4;5— r
a License lass _Lic.It "� SATURN AIR PD FOR BUS L I C 7/16/07 .
ro Date � Contractor ' t ^C sic L N
ARCHITECTS DEC
LA
w U 1 understand my plans shall be rued as public records
a
O y Licensed Professional
r OWNER-BUILDER DECLARATION
3 a M 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
.00 following reason.(Section 703 1.5,Business and Professions Cale:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
z y prior to its issuance,also requires the applicant for such permit to rile a signed statement
`e that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 St 1.Ft.Floor Area Valuation
3 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 8 6 O O
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Number
not more than five hundred dollars(s5W). 3265 6 0 2 2 A Occupancy Type
❑1,as owner of the property,or my employees with wages as their soic compensation,
will do the work,and the structure is not intended or offend for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law dos not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offend for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B do P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
�ve and will maintain a Certificate of Conscm to self-insure for Worker's Compen.
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this perm)t is issued.I shall not
employ any person in any manne !sh beta c subject to the Workers'Compensation
Laws 01C tor.Da
Applicant e,, -01
NOTICE A PLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z N CONSTRUCTION LENDING AGENCY
(-�— I hereby affirm that then is a construction lending agency for the performance of
Cl> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Z Lender's Address
U Q 1 certify that I have read this application and state that the above information is
r- correct.I agree to comply with all city and county ordinances and state laws relating to
rJ U building construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in cone hence of the granting of this permit.
APPL U DER STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by Date
SOU EGU ATIONS.
.�U
7` Re-roofs
Sign t o i ¢tor Date
AZARDOUS MATERIALS DISCLOSURE Type of R oof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)?
C]Yes PC All roofs shall be inspected prior to any roofing material being installed.
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
mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health c"yco c,Section25505,25533and25534.lundcm=dthatifthe building
does not a tly have t.nantuh at it is my responsibility b notify the occupant of the
require n hick mu ior to issua nce of a Ccnificale o n Signature of Applicant Date
� e All roof coverings to be Class"B"or better
Owner than.cd agent pate g