07010177 CITY OF CUPERTINO
BUILDING DIVISION PERMIT e� �G ��I�1RATION�
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: D TE
'IULTAPARIAH MUNIYAPPA &
,,,JIVHtN rTMTJ A SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION L� O
F= I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
e_ZW withScction7000)ofDivision3mftheBusincssandProfcssionsCodc,andmyliccnseis SFD REMODEL NON-STRUCTURAL INTERIOR LIGHOUT
0- in full force and effect r r
;yz License Class Lic.N REPIPE COPPER PIPES, 2 DOOR OPENINGS, KITCHEN &
F p Date Contractor
aARCHrrECrS DECLARATION BATH REMODEL, UPGRADE PANEL
19"
U 1 understand my plans shall be used as public records
a
4 0 ti Licensed Professional
n n OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p op� following reason.(Section 7031.5,Business and Professions Code:Any city or county
K !i 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
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or $20000
y 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 Q�N Number Occupancy Type
not more than five hundred dollars($500). 3262201-/
VV
❑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 Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q p
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 We.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
sate.).
Mlfeas 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 under c B&P C fo this on
'%caner �+ Date-'- �
WORK 'S COMPENS ORATION
1 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,far 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 Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars($100)
or less.)
I certify that in the performance pf the work or which this permit is issued.I shall not
employ any person in any markncqso as to the Workers'Compensation
Laws of California.D
Applicant
NOTICE TO APP CA :If,after ma in rtificatc of Exemption,you should
become subject to the Worker's Comps trte4[-on provisions of the Labor Code,you must
.J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z t" CONSTRUCTION LENDING AGENCY
I hereby aRirrn that there is a construction lending agency for the performance of
Cd> the work for which this permit is issued(Sec.3097,Civ.C.)
aQ Lender's Name
Z Lcnder's Address
U Q 1 certify that I have read this application and state that the above information is
iL t 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 properly for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
L.4) liabilities,judgments,costs and expenses which may in any way accrue against said City
U,Z in consequence of the granting of this permit.
•" APPLICANT U E STANDS AND}yILL COMPLY WI ALL N N-POINT Issued by: Date —Z
SOUR E REGU AT NS. e
19 Re-roofs
SignaturefApplicanontractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Rc of
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
Codc,Section 25532(a)? / All roofs shall be inspected prior to any roofing material being installed.
E]Yes Q44
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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes AY�o
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not curpwWk have a tenant that it' my responsibility toTfl'y the occupant of the
requiremen wh'h must be met prior ssuance of a CertificatOccupancy Signature e f Applicant Date
Owner r authori d agent - arc
All roof coverings to be Class"B"or better