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07090082 CITY OF CUPERTINO ' BUILDING DIVISION PERMIT Ga � }RMAZT�31 * PERMIT NO. BUILDING ADDRESS: 10530 N PORTAL AVE KAPIL & BHAVNA AGARWAL 07090082 PERMIT ISSUE DATE OWNER'S NAME: KAPIL & BHAVNA AGARWAL 10530 N PORTAL AVE 7 SANITARY NO. CONTROL NO. YE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH p Q LICENSED CONTRACTOR'S DECLARATION Job Description VP I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is INSTL 40 YR COMPOSITION BY T I MERL INE, 30 PD TAR r H in full force and effect License Class Llo•# PAPER ROLL 2 THICKNESS, 34 SQU, 1/2 INC OFB I t- Date contractor ARCHITECTS DECLARATION PLYWOOD .j ;M< 1 understand my plans shall be used as public records iwu ' U.r- Licensed Professional a OWNER-BUILDER DECLARATION 3 a I hereby atTirm that 1 am exempt from the Contractor's License Law for the p O following reason.(Section 7031.5,Business and Professions Code:Any city or county $9! which requires a permit to construct,alter,improve,demolish,or repair any structure "H prior to its issuance,also requires the applicant for such permit to rile a signed statement .Ft.Floor Area Valuation z a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 >q $3640 F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or °,�§ 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 �P�l Number Occupancy Type not more than five hundred dollars($500). 3163200") . V U ❑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 does 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.). ❑1.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 contractors)licensed pursuant to the Contractor's License Law. ❑I am empt under Sec. B&P C f r this reason �� G Owner WORKER'S CO NSATI N DECLARATION I hereby affimu under penalty perjury one o[the fallowing declarations: ❑I have and will maintain a Certificate of Consent 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. ❑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 (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 C li ornia.Date _ Applicant NOTICE T PPLICANT:If, f aki g this Certificate of Exemption,you should become subject to the Worker's Co nation provisions of the Labor Codc,you must ,J O forthwith comply with such provisiorVor this permit shall be deemed revoked. Z " CONSTRUCTION LENDING AGENCY [�. ►fir I hereby affirm that there is a construction lending agency for the performance of a.5 the work for which this permit is issued(Sec.3097,Civ.C.) W A L.endces Name z Lender's Address U 0 1 certify that I have read this application and state that the above information is E~- correct.I agree to comply with all city and county ordinances and state laws relating to 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 'moi liabilities,judgments•costs and expenses which may in any way accrue against said City U 2 in consequence of the granting of this permit. Date r, APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: S UR E REGULATIONS. 'O Re-roofs / Signa u of pplicanVContractor Date Type of F.00f ` HAZARDOUS M TERIALS DISCLOSURE yP Will the applicant or future b ' g occupant store or handle hazardous material as defined by the Cupertino Municipal ode.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 ❑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 contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? p Yes ❑No I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety Cade,Sections 75505,25533 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 i menta which must met prior to it�sttance ora Certificate of Occupancy. Signature of Applicant r r Date 6-.\`7 7 b All roof coverings to be Class 'B or better Owner or authorized agent Date CITY OF CUPERTINO 2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blh: Lot: APN . . . . . . . . . 31632009 .00 DATE ISSUED. . . . . . . : 09,'13/2007 RECEIPT #. . . . . . . . . : BS000002638 REFERENCE ID # . . . : 07090082 SITE ADDRESS . . . . . : 10530 N PORTAL AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . : KAPIL & BHAVNA AGARWAL ADDRESS . . . . . . . . . . : 10530 N PORTAL AVE CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2448 RECEIVED FROM . . . . : BHINNA AGARWAL CONTRACTOR . . . . . . . : LIC # *OWNER* COMPANY . . . . . . . . . . : KAPIL & BHAVNA AGARWAL ADDRESS . . . . . . . . . . : 10-)30 N PORTAL AVE CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-2448 TELEPHONE . . . . . . . . FEE ID UNIT QUANTITY !LMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ----------- ---------- ---------- ---------- BPERMFEE VALUATION 3, 640. 00 104 .76 0. 00 104.76 0. 00 BSEISMICRE VALUATION 3, 640. 00 0.50 0. 00 0. 50 0. 00 ----------- ---------- ---------- ---------- TOTAL PERMIT 105 .26 0. 00 105 .26 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 105 .26 #429 --------------- TOTAL RECEIPT 105.26 CITY OF C'UPERTINO ,� REPLOOF CUPE(,o TINO PERMIT APPL[CATION FORM APN# �j 6 — 3 ,z — d o Date: Building Address: (0-g3 o n(' po d4,Lo Ay 2 , �` e a C A y Owner's Name: KOP(,/ /�1�GY�`P gL I'A-a �,,,,,4 Phone#(c(m) <!R Contractor: n License#: Contact: l� Cupertino Business License #: Type of Roof Covering: Existing: Proposed: ❑ Built-Up Roof ❑ Built-Up roof ❑ ,Asphalt Shingles Ll Asphalt Shingles 0' Wood Shakes ❑ Wood Shakes ❑ Wood Shingles ❑ Wood Shingles ❑ Other(Specify) 0� Other(Specify) Number of existing coverings ❑ Provide I.C.B.O.Report# ❑ To be Removed ❑ Provide Mfgr.Installation Specs. I Have Read,Understand and Will Comply With Cu ertino's Tear Off Policy: Job Description:` ��`�' col -'W\0�kk �p a an Q rVA� ��_V y Residential "C&nmercial ❑ Fire Zone: Yes ❑ No Confirmed with Planning DjMt. if 11 there are any restrictions: LJ Cost of Project: Type of Consstruc':ion: Occupancy group: 3 Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE Bld,g Permit Fees BUILDING BENERGY I'sner BUILDING BSEISMICRE Seismic Fee Res BUILDING BSEISMICOM `>eismic Commercial BUILDING BPLANCHK I'Ian Check Fee BUILDING BUSLIC Business License BUILDING OWNER-BUILDF;R VERIFICATION 1. (Check one) I or my immediate family parent, spouse or child) will perform: A. ✓ All the work authorized by this permit B. _ A portion of the work C. None of the work If B or C is checked,complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. All of the work B. A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to be performed 3. I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone Number Type of work to be erf ormed ...............................................................................,..................................................................................................... I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner-Builder Information (reverse side). Property Owner's Signature: Date: Job Address: QTS Permit# Any changes to the information provided on chis form shall be submitted to the Cily of Cupertino Build Department. Community Development sw 10300 Torre Avenue Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 -,UPEI�TINO Building Department JOB ADDRESS: Q C, �A �v, PERMIT # D '? OWNER'S NAME: PHONE # GENERAL CONTRACTOR: FAX # 7---)�� I am not using any subcontractors: Si gnatur Date Please check applicable subcontractors and com plete the ollowin g information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date