06100046 CITY OF CUPERTINO Q � t� MATIO.
BUILDING DIVISION PERMIT CT�2A ;
PERMIT NO.
BUILDING ADDRESS:
884 S BLANEY AV C HA I YAR PERMIT IssuE DATE
OWNER'S NAME: 01/17/2007
CHAIYAR SIRIPOKE
SANITARY NO. CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
':ah P 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
=z w with Section 7000)of Division 3 of the Business and Prof Code.and my license is ADD I T I OIC : 9 4 2 ' — 2 BEDROOMS, 2 BATHROOMS,
°may in full form and 1 LIVINC ROOM, 1 DINING ROOM, 1 LAUNDRY ROOM.
v�z License Class L.ic.hf
:t-im Date Contractor REMODEL: 1518 ' — DEMOLISH 1 BEDROOM TO DINING RM,
ARCHITECTS DECLARATION
? I understand my plans shall be used as public records
a
LC H Licensed Professional
n yr
OWNER-BUILDER DECLARATION
< 1 hereby affirm that I am exempt from the Contractor's License Law for the
Q O following reason.(Section 7031.5,Business and Professions Code:Any city or county
e which requires a permit to construct,alter,improve,demolish,or repair any structure
Z r prior to its issuance,also requires the applicant for such permit to file a signed statementt;q,Ft.Floor Area Valuation
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $354875
:9 H (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 6 9 2 7 0 0� .W Number
not more than five hundred dollars($500).
❑1,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 Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of
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-
builder will have the burden of proving that he did not build or improve for purpose of
sale..
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 docs 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 u2r Se B&P C for thi reason
Owner Date
O N DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 Itsve 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.
Q 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 arc:
carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars(S 100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any Pers n in any mann so as to become subject to the Workers'Compensation
Laws of Calif a. It
tc
Applicant
NOTICE TO A a r akin,this Certificate of Exemption,you should
become subject to the Worker's C asation provisions of the Labor Code,you must
Z forthwith comply with such provisi or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
(^t hr I hereby affirm that there is a construction lending agency for the performance of
pG> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
0 z Lender's Address
I certify that I have read this application and state that the above information is
GUL� correct.I agree to comply with all city and county ordinances and state laws relating to
O V building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
>4 OW.h (We)agree to save,indemnify and keep harmless the City of Cupertino against
hE"y liabilities,judgments,costs and expe which may in any way accrue against said City
V`Z in consegtrcnc f the tin f IN permit. Date
►+ APPLICA D S A WILL COMPLY WITH LL NON-POINT Issued b}
SOURCE ULA ON . '
dRe-roofs
Signature of ApplicandContractor Dale T of Roof
MATERIALS DISCLOSURE Type
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)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes 0 N
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 r laterials for inspection.
District?
❑Yes ❑No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health& et ode,Se 'ons 505,25533 and 25534.I understand that if the building
docs not cu ntly ha 'a t it is my responsibility to notify tie occupant of the
mquimme while in be t anceofaCertificateu� — Signature;of Applicant Date
I All roof coverings to be Class"B"or better
Owner or authorrzcd agent arc