07050212 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � �R �� N* "
I
PERMIT NO.
BUILg211�,G L ltEsJOLLYMAN LN LOT 1 TBD - TO BE DETERMINED 07050212
BUJ PERMIT ISSUE DATE
OWNER'S NAME:
GUPTA, DIPESH 06/21/2007
SANITARY NO. CONTROL NO.
,NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0
p LICENSED CONTRACTOR'S DECLARATION Job Description
10W
P I hereby affirm that I am licensed under provisions of Chapter 9(commencing NO NEW
?z E with Section 70(X))of Division 3 of the Business and Professions Code.and my license is REVISION-TRUSS CALC S OR I G #07010005
n H in full force and effect.
PERMIT.
Z License Class Lle•M
p Dam Contractor
W ARCHITECTS DECLARATION
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1 understand my plans shall he used as public records
.yV
e u.y Licensed Professional
7 a OWNER-BUILDER DECLARATION
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1 hereby affirm that I 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
<m� which requires a permit to construct,alter,improve,demolish,or repair any structure
"y prior act its issuance,also requires the applicant for such permit to rile a signed statement Valuation
►< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 S a.Ft.Floor Area $0
is (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 Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 35922061 Number
not more than five hundred dollars($500).
❑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.).
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.
❑I am exempt under Sec B&P C for this mason
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Owner Date
WORKER' MPENSATION D CLARATION
hereby affirm under salty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Conant to self-insure for Worker's 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 imucd.I shall not
employ any person in any manner so3).AtLCoTesu 'ect to the Workers'Compensation
Laws of Caltfomia.Date
Applicant
NOTICE TO APP ANT:If,after m4tinjithis Certificate of Exemption,you should
become subject to the Worker's Compchaelon provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z OCONSTRUCTION LENDING AGENCY
[.�Ul I hereby affirm that there is a construction lending agency for the performance of
(:C > the work for which this permit is issued(Sec.3097,Civ.C.)
Lc1 QLender's Name
az Lender's Address
U 0 1 certify that I have read this application and state that the above information is
U. correct.1 agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorise representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
Ia. (We)agree to save,indemnify and keep harmless the City oC 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 EGULATIO S.
Re-roofs
Si azure of Applicant/ on r Da Type of R sof
H OUS 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(x)? All roofs.,hall be inspected prior to any roofing material being installed.
ClYes ver—_
If a roof i:,installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as do d by the Bay Area Air Quality Management all new m iterials for inspection.
District?
C]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.[understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements hick must be m pri°rw' cc of a Certificate of Occupancy Signature of Applicant Date
All roof coverings to be Class"B"or better
Own or authorized agent Ntc