06080004 CITE'OF CUPERTINO
BUILDING DIVISION PERMIT coI��GTC1R I�tFURMATI�N•
BUILTG ADDRESS: PERMIT NO.
21546 MONROVIA ST DAVIDMICHAEL CONSTRUCTION 06080004
'ER'S NAME: PERMIT ISSUE DATE
SITYAM & INDIRA DAVULURU 476 S. 2ND ST.
PHONE: SANITARY NO. CONTROL NO.
1 (408) 295-1919
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Q
O p LICENSED CONTRACTOR'S DECLARATION
v 1= 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
•z with Section 7400)of Division 3 of the Business and Professions Code,and my license is HOUSE DEMO
t=y in full force and effect
t4? License Class Lic.S
in Date Contractor
�'ii ARCHITECTS DECLARATION
WU 1 understand my plans shall be used as public records
a
o w Licensed Professional
OWNER-BUILDER DECLARATION
g I hereby affirm that I am exempt from the Contractor's License Law for the
`O O following reason.(Section 7031.5,Business and Professions Code: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 file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q.Ft.Floor Area Valuation
h$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y 2 that he is exempt therefrom and the basis for the alleged exemption.Any violation of $5000
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Number
not more than rive hundred dollars(s5M. 356230113
(1N Occupancy Type
❑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 or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does 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 offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
but.14er will have the burden of proving that he did not build or improve for purpose of
sal
,d I,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 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 M
pt 2ndpr Sec. B&P C for this reason
er Date
WOR 'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent 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.
❑1 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 am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
1 certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any man r I to cmc b'c the Workcrs'Compensation
Laws of Calif nia
Applicant
NOTICE LltXNT.If,a r making this dvertiricatc of Exchiption,you shouW
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z N CONSTRUCTION LENDING AGENCY
E h " 1 hereby affirm that there is a construction lending agency for the performance of
a> the work for which this permit is issued(Sec.3097,Civ.C.)
�W A Lender's Name
z Lender's Address
U Q 1 certify that I have read this application and state that the above information is
U. `- correct.I agree to comply with all city and county ordinances and state laws rclating to
C U building construction,and hereby authorize representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
,may co) liabilities,judgments,costs and expenses which may in any way accrue against said City
V z in consequence of the granting of this permit.
h" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 2 tj
SO CE' P"7! r R �+T�IO��NS' /,� 7 1 �1 � �
r
Signature ofApplican ntractor Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
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
dc,Section 25532(a)?
❑Yea ❑No All roofs slall be inspected prior to any roofing material being installed.
If a roof is:nstalled without first obtaining an inspection,I
Will the applicant or future building occupant use equipment or devices which g agree to remove P
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ONO
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&SafctyCode,Sections 25505.25533 and 25534.1 understand that if Ute building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
rcyu' men must be met prior w issuance a Certificate of Oc�ypanc Signature o'. Applicant Date
Owner or authorized agent / Date All roof coverings to be Class"B"or better