07050070CITY OF CUPER11Nv
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
19373 PHIL LANE
OWNER'S NAME:
VIJAYA PARUPALLI
)NE:
ARCHITECT/ENGINEER:
400 LICENSED CONTRACTOR'S DECLARATION
U3 I hereby affirm that I am licensed under provisions. of Chapter 9 (commencing
y with Section 7000) of Division 3 of the Business and Prof ons Code, and my license is
y in full force and effect
j ? License Clas Lre•
t p Date�Q 1� Contractor
AR�C7'S DELLA (�
j a< 1 understand my plans shall be used as public records G0 -4
)yU
U. H Licensed Professional
a OWNER. -BUILDER DECLARATION
aI hereby affirm that 1 ant exempt from the Contractors License Law for the
L p o following reason. (Section 7031.5, Business and Professions Code: Any city or county
< W E46 which requires a permit to construct, Alter, improve, demolish, or repair any structure
o " - prior to its issuance, also requires the applicant for such permit to rile a signed statement
- Z a that he is licensed pursuant to ft.. provisions of the Contractor's License Law (Chapter 9
xF (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 of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
❑ 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
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 conuacting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's U -
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 Contractor's
License Law.
❑ 1 am exempt under Sec. _ B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
».:..:
PERMIT NO.
THREE STAR CONST PAINT INC 07050070
PERMIT ISSUE DATE
603 ARCADIA TER STE 302 06/25/2007
SANITARY NO. CONTROL NO.
(800) 783-0707
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
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Job Description
ADDITION 488'-BEDRM/BATHRM/DINING/CLOSETS. ROOF
ON
ADDITION ONLY NOT REST OF HOUSE. THREE STAR CONST
'RENEWED BL. SANITARY IS SUNNYVALE'S JURISDICTION.
3750503C.
j I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
ation, 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 Workers Compensation Insurance, as required by Section
1700 of the Labor Code, for the performance of the work for which this permit is issued.
Ay Workee Co pensation Insuran carrier and Policy number are:
:arrier. Z Policy No.: X00
CERTIFICATE OF EXEMPTION FROM ORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars ($100)
ar 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 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
forthwith comply with such provisions or this permit shall be deemed revoked.
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.)
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
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 against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND LL C PLY WITH ALL NON -POINT
SOURCE REcureo
OnLraifor re
HAZARDOUS MATERIALS DISCLOSURE
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
Code, Section 25532(a)? �L
E]Yes o
Will the applicant or future building occupant use equipment or devices which
_mit hazardous air contaminants as defined by the Bay Area Air Quality Management
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 tenan my responsibility to notify the occupant of the
requirements M*iEh must b% et prior w i ance of a Ccru icate of Occupancy.
Owner or authorized
Issued b)
Re -roofs
Type of Roof
Ft. Floor Area
$104612
Required Inspections
occupancy
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new r iaterials for inspection.
Signature; of Applicant Date
All roof coverings to be Class "B" or better