07080192 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILI�IIU,pTFtESN PERMIT NO.
BLANEY AVE COOL' S CUSTOM 07080192
OWNER'S NlAMEE: PERMIT ISSUE DATE
PATEL, GITA 4718 MERIDIAN AVE 09/24/2007
)NE: (408) 353-9692 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i
00 LICENSED CONTRACTOR'S DECLARATION Job Description
P I hereby affirm that I am licensed under provisions of Chapter 9(commencing
ZU with Section 7000)of Division 3 of the Business and Professions Code,and my license is REMODEL MASTER BATH, HALL BATH, DOWNSTAIRS 1/2
h j y in full force and c t %/ / U
z License class Lic.x 7 / BATH
t tip
Date RCHITECTS DECLARATION
onderstan my plans shall be used as public records
7yU
U. Licensed Professional
y OWNER-BUILDER DECLARATION
3� d hereby affirm that 1 am exempt from the Contractor's License Law for the
Oa following reason.(Section 7031.5,Business and Professions Code:Any city or county
e$V which requires a permit to construct.alter,improve,demolish,or repair any stricture
Zy prior to its issuance,also requires the applicant for such permit to file a signed statement
=o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
e.F$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $36000
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 Number Occupancy Type
not more than five hundred dollars(5500). 3 16 2 3 0 3 9
❑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 ns Required Inspections
and Professions Code:The Contractor's License Law docs 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 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 of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Cont actoes Li-
ccnse 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 Contractors
License Law.
C]I am exempt under Sec. B&P C for this reason
OwnerDate
WORKER'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 WorkersCompen-
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 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 Workeees Compensation Insurance carrier and Policy number are:
Carrier. !Q74 77_r"� LfF�1.� Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKE S'
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.I 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
Fr I hereby affirm that tore is a construction lending agency for the performance of
LY. the work for which this permit is issued(See.3097.Civ.C.)
ALender's Name
Z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
r-+ correct.I agree to comply with all city and county ordinances and state laws relating to
y building construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue againstsaid City
U Z in consequence of the granting of this permit. Date
�+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
/01
` B� Re-roofs
Sig Lu of Appli tort
OUS MATERIALS DISCLOSURE Type of Roof
Will to appli or future building occupant store or handle hazardous material
as defined by the Cu rtino �N�o
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
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?
Cl Yes o
1 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 currently have a tenant that it is my responsibility to notify the occupant of the
requirements which must be mel 'or to issuance of a Ccruftcatc of Occupancy Signature of Applicant Date
All roof coverings to be Class "B"or better
Owner or a honrc agent