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09010049LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9 (commencing vith Section 7000) of Division 3 of the Business and Professions Code. and my license is CLOSE SWIMMING POOL MEMO) n full force and cllect .icensc Class Lic. )ate Contractor ARCHITECTS DECLARATION 1 understand my pians shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors License Law for the following mason. (Section 70313. Business and Professions Code: Any city or County which requires a permit to construct, alter, improve. demolish, or repair any structure 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 (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or 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 not more than five hundred dollars (5500). ❑ I. as owner of the property. or my employees with wages as their sole compensation, will do the work, and time structure is not intended or offered for sale (Sec. 7044. Business and Professions Code: The Contractor's License Law docs 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 tonstntct the project (Sec. 7044. Business and Professions Code:) The Contractor's U cense Law u not roperty ho builds or roves thereon, and. who contracts fapply or suchprojects with a contractors) liceensed pursuant to the Contractor's dense Law. B& P C r r this r9ason ❑ I am exempt under See 1 Owner �- Date f W K 'S C ENSATI N DECLARATION 1 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- ..on, as provided for by Section 3700 of the Labor Cote, for the performance of the work for which this permit is issued. ❑ I 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 Workers Compensation Insurance carrier and Policy number arc: 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,) shall not employ any person in any manner •a� lect to Ore workers' Cageensation Laws of Calif is Ds df Applicant NOTICE 7'O PPLIC : If, after making this Certitirarc of Exemption, Au should become subject to the Workces Compensation provisions of the Labor Code, you must Oforthwith comply with such provisions or this permit shall be deemed mvokcd. 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 Lenders Name 0 Z [coders Address U Q I certify that I have mad this application and state that the above information is LI. correct. I agree to comply with all city and county ordinances and state laws mlating to 0 U building construction, and hereby authorize representatives of this city to enter upon the W above-mcndonad property for inspection purposes a (we) agree to save, indemnify and keep harmless the City of Cupertino against r..4 liabilities, judgments, costs and expenses which may in any way acme against said City C.) Z in consequence of the granting of this permit. �-r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SO?RC9�Applican ONS. ; - .L y Signature tot Da OU�MATERI JS:D2CLDSLRE 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)? ❑ Yes No Will the applicant or future building occupant use equipment or devices which it hazardous air contaminants as defined by the Bay Area Air Quality Management ,trict? ❑ Yes )kNo 1 have mad the hazardous materials requirements under Chapter 6.95 of the califor- nia Health & Sarcty Codc, Sections 25505, 25533 and 25534.1 understand that if the building does not currently `h�aLve a tenant. that it is my responsibility to notify the occupant of the rcq whic¢tust be mel prior to i trans of a Certificate of cupancy Date Sq. Ft. Floor Area 36205003.00 umber I Occupancy Type Required Inspections Issued by: Date Re -roofs — Type of Roof All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant Date All roof coverings to be Class 'A"' or better 3 ITEMS OF 3 CITY OF CUPERTINO PERMIT RECEIPT Sec: Twp: Rng: Sub: Blk: Lot: APN ......... 36205003.00 DATE ISSUED.......: 01/12/2009 RECEIPT #.......... BS000006952 REFERENCE ID # ...: 09010049 SITE ADDRESS .....: 21450 COLUMBUS AVE SUBDIVISION ....... CITY CUPERTINO IMPACT AREA ....... OPERATOR: patg COPY # : 1 OWNER NATARAJAN BANGALORE R ADDRESS ..........: 21450 COLUMBUS AVE CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4971 RECEIVED FROM ....: B R NATARAJAN CONTRACTOR LIC # *OWNER* COMPANY ..........: NATARAJAN BANGALORE R ADDRESS 21450 COLUMBUS AVE CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4971 TELEPHONE ......... FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW BAL ---------- ----------------------- 1BCBSC VALUATION ---------- 1,000.00 ---------- 1.00 ---------- 0.00 ---------- 1.00 0.00 1BSEISMICR VALUATION 1,000.00 0.50 0.00 0.50 0.00 1DEMOPRE SQUARE FEET 0.00 490.00 0.00 ---------- 490.00 ---------- 0.00 ---------- TOTAL PERMIT ---------- 491.50 0.00 491.50 0.00 METHOD OF PAYMENT ----------------- CHECK TOTAL RECEIPT : AMOUNT --------------- 491.50 --------------- 491.50 REFERENCE NUMBER -------------------- #7109 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 704 DEMO 50% CITY Of CUPERTINO CITY OF CUPERTINO DEMO PERMIT APPLICATION FORM u�ol oo4q APN# Fee ID Date: l Z/q 2(pkoi v U Permit Type Building Addr ss: c Demo -Residential B Mailing Address (if different from building address): Owner's Name: A�� TA)v 6 PG Cr�_ Pool Demo Residential Phone: Contractor Phone Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICRE Fax: Contractor License #: Cupertino Business License #: Contact: Phone: Fax: Residential Sq Footage Commercial ❑ Sq Footage Job Descr}ption: Valuation: /--u Project Size: Express Dl ---/Standard ❑ Large ❑ Major ❑ Please complete relevant portions of the Green Building Checklist & attach it to the application or if applicable, include on the plan set & the sheet index. d1 Quantity Fee ID Fee Description Fee Group Permit Type 1DEMORES Demo -Residential B 1SFDWL-DEM 1DEMOPRES Pool Demo Residential B 1SFP00L-DEM 1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICRE Seismic Residential B Revised 01/07/09 Project has not yet met the following recommended minimum requirements: - Total Project Score of At Least 50 Points - Required measures: -A3a: 50% waste diversion by weight -32: 15% above Title 24 -NI: Incorporate Green Point Rated Checklist into blueprints - Minimum points in specific categories: -Energy (30 points) -IAQ/Health (5 points) -Resources (6 points) -Water (9 points) r 0 2007 Build It Green Single Family GreenPoint Cheddist 2007 Version Page 7 of 7 OWNER -BUILDER VERIFICATION 1. (Check one) I or my immediate family (parent, spouse or child) will perform: A. All the work authorized by this permit B. _ A portion of the work C. _ None of the work If B or C is checked, complete 2 or 3 below. 2. A state licensed contractor will be hired to do: A. _ All of the work B. _ A portion of the work (complete section below) Contractor Address/City Phone # State License # Type of work to be performed 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or portions of the authorized work. I understand that I may be an employer (see reverse side). A Certificate of Insurance covering workers' compensation must be on file at the City of Cupertino Building Department office. Person/Firm Address/City Phone NumberI Type of work to be performed I declare under penalty of perjury that the above is true and correct. I have read and understand the Owner -Builder Information (reverse side). Property Owner's Signature: Date: Job Address: Z t 50 CO C� Permit # Any changes to the information provided on this form shall be submitted to the City of Cupertino Build Department. CITY OF CUPEkTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADDRESS: VM -g Vs v _ C b' - l /u 0 PERMIT # SUBCONTRACTOR BUSINESS NAME OWNER'S NAME: ��,►� II MA 93"A`' PHONE # O -- Z -S L --3 �,8 GENERAL CONTRACTOR: 61,_� lVF- p- V V t L 6 c K FAX # I am not using any subcontractors: C S Date Please rherk applicable subcontractors and comvlete the following information: + SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile 0 ontractor Signature Date