07070141 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �� '
PERMIT NO.
BUILD�N�PSD�RF�$:,VEMBER DR SHAH, D'.'sEPA 07070141
G lV 11 PERMIT ISSUE DATE
OWNER'S NAME:
SHAH, DEEPA 1221 CR-ESCENT TERRACE 09/25/2007
SANITARY NO. CONTROL NO.
jNE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
Q (� 0
p o LICENSED CONTRACTOR'S DECLARATION Job Description
C 1 hereby affirm that I am lid under provisions of Chapter 9(commencing ADDI T I O=AT OF 876 SQUARE FEET FOR FAMILY ROOM AND
z r with Section 7000)of Division 3 of the Bcenseusiness and Professions Code,and my license is
�y in full force andcffect- MASTERBEDROOM, PARTIAL GARAGE CONVERSION, NEW BAY
r n z License Class Lte•B
o Date contractor WINDOW, NEW FRONT PORCH AND 2 SKYLIGHTS
: ARCHITECTS DECLARATION
i < I understand my plans shall be used as public records
)A.0
U.I Licensed Professional
y
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
pO 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; prior to its issuance,also requires the applicant for such permit to file a signed statement 3 ,Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $95200
t t� (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
Q that he is exempt therefrom and the basis for the alleged exemption.Any violation o[ Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 36216001 . bT Number
not more than five hundred dollars($500).
0 I,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure isnot intended oroffered 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
sad.)
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 Contractoes
License Law.
0 1 am exempt under Sec. B&P C for this reason
Owne��= /iib _Date
W ER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑i hsve and will maintain a Certificate of Conscnt to self-insure for Workces Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 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 permit is issued.1 shall not
employ any person in any manner;o ls'berpme bject to the Workers'Compensation
Laws of Cali Vc
Applicanr —
NOTICE TO APPLIC :If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
(.. ►-. 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.)
Lfl Q Lender's Name
Z Lender's Address
U 0 I certify that 1 have read this application and state that the above information is
iL. E' correct-I agree to comply with all city and county ordinances and state laws relating to
0 U building construction.and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
fn liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date 2 C
►+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b):
SOURCE EGULATT S.
� Re-roofs
Signature of A licant/Comractor Date Type Of Roof
HAZARDOUS MATERIALS DISCLOSURE yP
Will the applicant of future building occupant store or handle hazardous material
as defined by the Cupertino M;umc, al 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.
0 yes 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
emit hazardous air contami;;-No
as d fined by the Bay Area Air Quality Management all new r laterials for inspection.
Ldocs
Yes
have read the hazardous materials requirements under Chapter 6.95 of die Califor-
h&Safety Code,Sections 25505.25533 and]5534.1 understand that if the building
currently have a tenant,that it is my responsibility a notify the occupant of the
ents which must be met prior a issuance of a Certificate of_Oc pawY. S ignaturt•of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorircd agent Date