06110100 CITY OF CUPERTINO
BUILDING DIVISION PERMIT TQC Il� tlRMA' I€IN, .
PERMIT NO.
BUILDING ADDRESS:
22115 CLEARWOOD CT MIKE SP7VEY
PERMIT ISSUE DATE
OWNER'S NAME:
SUNIL MALKANI 901 CAMDEN AVE UNIT 4 01/04/2007
SANITARY NO. CONTROL NO.
'ONE: (408) 866-4392
BUILDING PERMIT INFO
ARCHITECT/ENGiNEER: BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
Z with Section 7000)of Division 3 of the Busaffirm that I am licensed tiness and Professions Co/nder provisions of pm and my license is AD I TION 225 ' -EXTEND FAMILY ROOM & ADD SMALL DEN
y in full force and effect ! 0 LAUNDRY
n? License Class Lic.,v
3aw Date -•n 4 .n✓1 ContrsdorALK
ARCHITECTS DECLARATION
ce W U I understand my plans shall be used as public records
v
H Licensed Professional
n 0 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
%p O following reason.(Section 703 1.5,Business and Professions Code:Any city or county
which requicsesra rmit to construct,alter,improve,demolish,or repair any structure
z; prior tri is ivanccpe,also requires the applicant for such permit to file a signed statement S Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $48233
xF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
W_ that he is exempt therefrom and the basis for the alleged exemption.Any violation of Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 2 618 0 3 )
not more than five hundred dollars($500).
❑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.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or impmves 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.).
❑1,as owner or 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 under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I 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.
❑I have and will maintain Workers 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 Insurrance carrier and Policy number are:
Carrier.VT A T'� �� 1try No. 'Zvy
RTWEATE F FXEMIPTION FROM WO
COMPENSATION INSURANCE
(This 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 permit is issued,1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date—
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J z forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
►N. I hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q
Lender's Name
0. Lendees Address
1 certify that 1 have read this application and state that the above information is
LUL correct I agree to comply with all city and county ordinances and state laws relating to
O V building construction,and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
>4 a (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 consequence of the granting of this permiL Date / r
-POINT Issued b�:
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON
SOURCE REGULAT S. I J_
fatf! % 1`04 'a/ Re-roof:
Signature ofApplicanUCon Due 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 roof:;shall be inspected prior to any roofing material being installed.
❑Yes L11 no
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
omit hazardous air contaminants as defined by the Bay Area Air Quality Management all new naterials for inspection.
District?
❑Yes u
1 have read the hazardous materials requirements under Chapter 6.95 or the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant.that it is my responsibility to notify the occupant of the
requirements which must Amet prior to issuance or a Certificate of occupancy. $ignatui a of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorized agent Date-