07040066 CITY OF CUPERTINO77
BUILDING DIVISION PERMIT
BUILDV8 RESS: PERMIT NO.
���D� SEPTEMBER DR TBD TO BE DETERMINED 07040066
OWNER'S NAME: PERMIT ISSUE DATE
PRASAD ADEM 05/01/2007
NE: SANITARY NO. CONTROL NO.
ARCHI IECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o a o 0
o o LICENSED CONTRACTOR'S DECLARATION Job Description
VUW I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 70W)of Division 3 of the Business and Professions Codc.and my license is REV I S I C N-FLOOR JOISTS 4 X 6 & PIERS ADDED TO THE
y in full force and effect.
t�z
License Class Lic.N APPROVED PLANS-ORIG PERMIT #06080047-NO NEW
:—a Date Contractor
lt:wARCHITECTS DECLARATION PLANS-CONTRACTOR POLO PEREZ HAS CURRENT BL #28774
7 a< 1 understand my plans shall be used as public records
)yV
a y Licensed Professional
ya OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
COO following reason.(Section 7031.5,Business and Professions Code:Any city or county
e.Psi which requires a permit to construct,alter,improve,demolish,or repair any structure
Ll Z} prior to its issuance.also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor AreaValuation
r I=- (commencing with Scction 7000)of Division 3 of Ute Business and Professions Code)or $0
1. 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 A Number Occupancy Type
not more than five hundred dolhtrs(5500). 36215020 .
❑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 Contractor's License Law docs not apply to an owner of q p
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.).
t,as owner of the property,am exclusively contracting with licensed contractors to
c nstmet the project(Sec.7044.Business and Professions Code:)The Contractor's U.
cease Law does not apply to an owner of property who builds or improves thereon,and.
who contract;for such project with a conueacwr(s)licensed pursuant to the Contractor's
*;cense Law.
,rise exemptand See B&P C for this reason
Owner C Date
WOICKER'S CO PENSATIONCLARATION
101
I hereby affirm under penalty of perjury one of the following declarations:
J I have and will maintain a Certificate of Consent 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:
Cartier. 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 certiCy that in the performance of the work for which this rmit is issued.1 shall not
employ any person in anym�{ u w to become cc Workers'�tynpc� 'on
Laws of California.Date cftkas /'
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
,J z forthwith comply with such provisions or this permit shall be deemed revoked.
0
Z, CONSTRUCTION LENDING AGENCY
[~i 1 hereby affirm that there is a construction lending agency for the performance of
(Ya�✓ the work for which this permit is issued(See.3097,Civ.C.)
W�.Q Lender's Name
a Z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
V.r—' correct.I agree to comply with all city and county ordinances and state laws relating to
0 Vbuilding 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
.rA liabilities,judgments,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 COMPLY WITH ALL NON-POINT Issued by:
SOURCE U TIONS. r—
R 0 Re-roofs
Signature of Applicant/Contractor I jDatc
HAZARDOUS MATERIAL DISCLOSURE Type of R jof
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)? 1 All roofs:;hall be inspected prior to any roofing material being installed.
❑Yes �y No
future building occupant use equipment or devices which If a roof i:.installed without first obtaining an inspection,I agree to remove
Will the applicant or
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District? ���ppp
❑Yes Ly No
1 have read the hazardt�s`materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant.that it' responsibility to notify the occupant of the
mq mien moat be t prior isau of a cerlira:ate of $ Signature Of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorized agent ate