07050213 777=77..7.7777777777=
CITY OF CUPERTINO
BUILDING DIVISION PERMITRA
PERMIT NO.
BUIL�r�Gff..JOLLYMAN .LN LOT 2 TBD — TO BE DETERMINED 07050213
�J PERMIT ISSUE DATE
OWNER'S NAME:
GUPTA, DIPESH 06/21/
SANITARY NO..
CONTROL NO.
)NE:
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB b(ECH
0 0 a a
p Q LICENSED CONTRACTOR'S DECLARATION Job Description
m" 1 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 REVISION—TRUSS CALC S OR I G PERMIT 06100074 NO NEW
y in full force and effect.
r�Z License Class Lic.8 PERMIT.
Contractor
t— Date ARCHITECTS DECLARATION
J
UI understand my plans shall be used as public records
U.y Licensed Professional
O a OWNER-BUILDER DECLARATION
y J
I hereby affirm that 1 am exempt from the Contractor's License Lawar the
pO 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
prior m its issuance,also requires the applicant for such permit to file a signed statement Valuation
°Z r p q.Ft.Floor Area $
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 0
V.t=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i 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 3 5 9 2 2 0 61 Number Occupancy Type
not more than five hundred dollars(SSW).
❑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 Required Inspections
and Professions Code:The Conuactoes 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.).
tV 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 Contractor's
License Law.
❑1 am exempt under Sec B&P C for this n
O
Owner tc Date
O ER' C MPENSATION DECLARATION
1 reby affirm under penalty of perjury One of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compcn-
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 foronc 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 as co c b" to the Workers'Compensation
Laws of Califomia.Date
Applicant
zr
NOTICE TO APP CAM:If,after ing this Certificate of Exemption,you should
become subject t6 the Worker's ComiVinsation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z "" CONSTRUCTION LENDING AGENCY
H ►�-+ 1 hereby affirm that there is a construction lending agency for the performance of
r7 the work for which this ppeep�mmit is su ec.3097, iv.C.)
W Q Lender's Name i� +
ate-
► z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
H 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 ahove-mentioned property for inspection purposes.
CL (We)agree to save,indemnify and keep harmless the City of Cupertino against
V] liabilities,judgmcnts,costs and expenses which may in any way accrue against said City
U ,Z in consequence of the granting of this permit. Date !/-
�" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE RE ULT! S.
A Re-roofs
Sign rco(ApplicanUC tract °a Type of RJof
HIAZ MATERIALS DISCLOSURE YP
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)? �� All roofs:;hall 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 i:;installed without first obtaining an inspection, agree to remove
emit hazardous air contaminants as dcf)ncd by the Bay Area Air Quality Management all new materials for inspection.
District? '�,�
❑Yes ❑No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cork:,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
rcquimmc tswhich me aruy4ssuanccofaCertificateofG«opanry. Signature of Applicant Date
D All roof coverings to be Class 'B or better
ncr or authorized agent tlDatc