08090149 CITY OF CUPERTINO I ff:iF nape 'fir„->t =�P' 'fir- "'�
BUILDING DIVISIONPERMIT '.'CoNTRAG'''TQR Ii k'URMATION '
BUILDING ADDRESS: PERMIT NO.
10153 COLBY AVE TBD - TO BE DETERMINED 08090149
NER'I NAME. PERMIT MSUB DATE
rGOPAL SANKARANRAY 10/10/2008
PHONE: - SANITARY NO. CONTROL NO,
ARCHI ECT(ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
I� � I�
uoo LICENSED CONTRACTORS DECLARATION i� UOn 1 hereby affront that 1 sol Job DttSCT1 licensed under provisions of Chapter 9(commencing p
wiNkc0an70(10)ofDivWon3oflheBudneuaedPmfu=Co .udmylicemIs SFDWL ADD(195SQ) BDRM & RMDL 1 EXT BDRM INTO MSTR
>q= nfallfaomand 6L C Lle.R g BTH&CLOSET(120SQ&RE-RF 18SQ & NO STRUCTRL
z License Crew
^p Dam cuta ecbr
e r$7W ARCHT(ECI'S DECLARATION
WU 1 underrated my plane shall Ise med u public mcoms '
SG In Liceasad Professional
3 OWNER-BUILDER DECLARATION
I I hereby affirm Nu I am exempt from t.i
the Contractors eento Law for the
no following mason-(Section 7(1313,Business and Prefessians Cade:Any city or county
a ff which requires a permit m carseat Wu.Improve.demol"ta,.or repair any s mem.
zY prior at its issuane.also requires theapplieant for such permit to rile a signed stammer,
N< mad he is licensedpurauanttomcprovisionsoftheConuacoxYlicenselaw(Chapter9 Sq.Ft. Floor Area Valuation
5 (commcmingwith Section 700MofDivision 3ofthe Business and ProfessionsCode)., $30 00
Q`;^ dust W Is csempt therefrom and the We.for the alleged exempfiot.Any vWshio.of
Section 7031.5 by airyapplicant fora permit subjects theaPplicaed W.ciil penalty of AEF64 Occupancy wt mom man r.hundred dollars(M). 31628045 !V� Pane Y T yPe
0 1,as awns of tine property,or my employees wuh wage an their sole compereadon.
will do dm work,and theseuctum le not intended moncred for atm(Sec.7044.BM—
and
and Proressm.code:The cmaccmrs License law does not apply m an owner of Required Inspections
property who Wilda or improv t o mon,and who does such work himself or through his
awn employees,provided door such improvements are not intended or offered for sale B.
however,Ne Wilding or Wprovement is sold within arc year of completion,met ownes-
Wildsr will Ww dr buNen or proving mat K did ant htilo or improve(or purpoo a
❑1,u owner of tine PmPerty,am exclusively contracting will,Bcemnd com actms m
camstran the omynct(Sec 7(361.Business and Preferences;Cade:)The Canuacmh LL
c"".-Law does out apply an an owner of property who builds or improve Nemo.,and.
who comment for such projects with acanuactor(s)licensed pursuant to the Canuaemrs
License Law.
❑Iamessmptundersee .BRPCfmmisrtsaov
mer Date
WORKER'S COMPENSATION DECLARATION
I hereby antem under penslty of perjury oro of tine fallowing declarations:
Qt,I Wve and will maintain s CatiBomof Cantu amaelf-insert for WorkersCompen-
sation,as provided for by Section 3700 of me Labor Code,for the PerPonnance of the -
work for which this permit is issued.
Q 1 haw ted will maintain Workers Compenuadon losurana,u mquirtd by Section
3700*(the lobar Code.for the pemarmanceof the work farwhich mit Permit is issued.
My Workers Compensation Inwmece carrier and Policynumber art:
Carrier, Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need out completed if the Permit h fmune hundred dollars;($100)
or heat)
1 rectify mat in the perforreanee of f.,it foo which this permit u issued,I WWII nm
cesploy any person in aey mape0crw op m becggmPuubjem da me Wedscri Co epensado.
Laws of California.DDeam / ((ll UJ YY
AppEont 'SQA s L! C.
NOTICE TO APPLICANT:If,error making this Cenieum of Esemption,yap should
become subjw in the Wohers Compensation previsions of me lahor Code,you mon
.,O forthwith comply with such provisions m this Permit shall ed dccmW conked.
EP%1 CONSTRUCTION LENDING AGENCY
[-, I hereby affirm that then u a compunction lending agency fm the performame of
p$ r>-r she work for which this permit is issued(Set 3(447,Civ,C.) ,
C Lender's Name
z lenders Address
U O I certify mat 1 Ww read this application and rum this the above Information is
IL E Correa I agree in comply wish all city and county ordiwmtts and sum laws relating in
C) building construction,and hereby mmorire rtprtsenuliws ofmu city to enter upon me
WaWw-matdoned property for inspcnian purpo¢s
P. (We)agree Int raw,indemnify and keep homeless the City of Cupertino against
i
liabilities,judgments.casts and expensns which may in any way seem against said City
U z in consequence of me go nung of this pcmiL /
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE ULAMOJS
Signature Dam
- - Re-roofs
pplmCanIA]ARDOUS MATERIALS DISCLOSURE Type of Roof .�-
WIrmc,applicars,or future building ocmpant some or handle hasamou material
40 dcBned by she Cupertino Municipal Code,Chapter 9,12.and the Health and Safety
k.Seed.255324)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes IAN.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the it coma or future Wilding by me B y A equipment of Mara which g
emit huardnu it contaminants u JcOned by the Bay Ana Air Quality Management all new materials for inspection.
ITatri<t7
❑Yes dNo
1 haw mad the haramm smmaterials nemirtmcnts under CWpmr 6.95ofthe Califon
nu Health&Safety Cade.Sections 25505.25533 and 25534.l undemued con if the Wilding
dap not currently haw a mrtsnl that it is or,responsibility in netiry she ocoupant of me
requirtmen kbmura =Ipdermhuanceof.Ccnir7y1f0ccmpstmy. Signature of Applicant Date
1. 1` ID -lo-v
All roof coverings to be Class';W'or better
Owner or aura'cd a t Dam'
r