06020072 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ® TT �� '
BUILDING ADDRESS: PERMIT NO.0 6 0 2 0 0 7 2
10846 WILLOWBROOK WY
OWNER'S NAME: PERMIT ISSUE DATE
SAMEER NANDA 04114/2006
SANITARY NO. CONTROL NO.
E:
ARCH1TECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i p C LICENSED CONTRACTOR'S DECLARATION Job Description
V
p I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 70(X))of Division 3 of Ute Business and Professions Code,and my license is
;7<2
y in full force and effect. ADD 677 ' MAS TER BED/BATH-REMODEL ENTRY
License Class Lic•#
L E un Dam Contractor
ARCHITECTS DECLARATION
a< 1 understand my plans shall be used as public recordsuJ
,4U �G
t F' Licensed Professional
0,
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the l
Cp Oa following mason.(Section 7031.5,Business and Professions Code:Any city or county
W ! $142984
which requires a permit to construct,alter,improve,demolish,or repair any structure
Zy prior to its issuance,also requires the applicant for such permit to file a signed statement
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
Y.
t-$ (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 3W:NWeruo Occupancy Type
not more than five hundred dollars($500).
❑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 Re wired Ins ections
and Professions Code:The Contractor's License Law does not apply to an owner of 9 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.).
❑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.
❑lam exempt on "Irk` B&P C for this reason
Owner Date
.0 OMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
lJ 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 Workees Compensation Insurance carrier and Policy number art::
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
r
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performan gf.thaw rk for which it is issued.I shall not
employ any person in an,. F ecu to the Workers'C cnsation
Laws of Cal'
roroi
Applicant
NOTICE r making this CertiGca f Exem ton,you should
become subjec orker's Compensation provisions of the Labof Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
z" 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.)
W A Lender's Name
az Lenders Address
U O I certify that 1 have read this application and state that the above information is
LL r- correcL I agree to comply with all city and county ordinances and state laws relating to
O U building construction.and hereby authorize representatives of this city to enter upon the
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above-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Hliabilities,judgments,costs and expenses which may in any way accruc against said City
U Z in consequence of the g.,, ' perm-
r APPLICANT U COMPLY WITH ALL NON-POINT Issued by: Date C/
SOURCE IjIEC �• —�
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Si Re-roofs
PP HAZARDOUS MATERIALS DISC E are Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino MrN.
' al Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Willthe applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
-.nit hazardous air contaminaVN
defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes
I have read the hazardous materials requirements under Chapter 6 95 ofibe califor-
nia Health&Safety Code.Scc' 23565' 533 and f gpdarsUfid that if the building
docs not currently s m nutty to notify the occupant of the
requirements w' cc of a certificate of OccuPan . Signature of Applicant Date
hor,zed agent Date All roof coverings to be Class"B"or better