06100045 CITY OF CUPERTINO
BUILDING DIVISION
PERMIT
PERMIT NO.
BUILDING ADDRESS: SUMAL NAVKI RAN 06100045
10418 MIRA VISTA AV
PERMIT ISSUE DATE
OWNER'S NAME:
SUMAL NAVKIRAN 10/26/2006
SNE: SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ARCHITECTIENGINEER:
BLDG ELECT PLUMB MECH
!0p LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
.Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is
CL in full farce and effect ARBOR AT REAR YARD
> ? License Class Lic.#
t tp Date Contractor
ARCHITECTS DECLARATION
,a
U 1 understand my plans shall be used as public records
C H Licensed Professional
y OWNER-BUILDER DECLARATION
a 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Calc:Any city or county $3000 O O 0
,0,Pi which requires a permit w conswct,alter,improve,demolish,or repair any swcture
Z y prior to its issuance,also requires the applicant for such permit to rile a signed statement
2C`e that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
r.
RE- (commencing with Section 7000)of Division 3 of the Business and Professions Cade)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 r U Occupancy Type
not more than five hundred dollars($500).
0 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 Cafe:The Contractor's License Law does 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.).
0 1,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.
0 I am exempt under S c B&P C for this reason
Owner N Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
0 1 have and will maintain Workers 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 issued,1 shall not
employ any person in any manner so as to bc�o a sub�ct tq the Workcrs'Compensation
Laws of California.Date 11 I 1 t1G
Applicant w'A
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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
[~—h►�-� 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.)
Irl QLender's Name
2 z Lcndees Address
U 0 1 certify that I have read this application and state that the above information is
u3, correct.1 agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
Q. (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
V Z in consequence of the granting of this permit.
►� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date e16 "2
SOURCE REGULAT,,Igqc��S.
I'` vJ] Re-roofs -� —
Signature of Applicam/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes 0 No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes J]No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&SafetyCodc,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
requirements which must Kc met prior to issuance of a Certificate ofa,pancy. Signature of Applicant Date
14,10 b
All roof coverings to be Class"B"or better
Owner or authorised agent Date