09010106 CITY.OF CUPERTINO
BUILDING DIVISION PERMIT GIRATC?R: � � Tra�rw
BUILDING ADDRESS: PERMIT NO.
10559 STERLING BLVD HARI SATRIYA
OWNER'S NAME. PERMIT ISSUE DATE
rN0 SA CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ELECTRICAL PANEL UPGRADE 200 Q Q Q Q
�o p LICENSED CONTRACTOR'S DECLARATION AMP
V I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 70()0)o1 Division 3 of the Business and Professions Code,and my license is
o=y in full foto and effect.
Z License Class Lic.if
3!:9
t;,a Date Contractor
ARCHrmcrS DECLARATION
4
v I understand my plans shall be used as public records
Dw
4 It.y Licensed Professional
n y OWNER-BUILDER DECLARATION
ys< I hereby affirm that 1 am exempt from the Contractor's License Law for the
r Q O following mason.(Section 703 1.5,Business and Professions Code:Any city or county
4 which requires a permit to construct,alter,improve,demolish,or repair any structure
y 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 Area Valuation
yF--0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars(5500).
❑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
and Professions Code:The Contrxtor's License Law does not apply to an owner of Required Inspections
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.
❑1 am exempt and Seo. B&P Clfor this reason
Owner ; Date 1
WORKER'S COMPENSAntV DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insum 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 am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Ibis 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,I shall not
employ any person in any manncrr l aorto coTeesubject to the Workers'Compensation
Laws of California.Date l�
Applicant =,
NOTICE TO APPLIOANT:If,after making is Ccrtiftcate 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
-t rA I hereby affirm that there is a construction lending agency for the performance of
a> the work for which this permit is issued(Sec.3097,Civ.C.)
aA Lender's Name
►7 z Lender's Address
U 0 I certify that I have read this application and state that the above information is
V. correct.I agree to comply with all city and county ordinances and state laws relating to
0V building construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. —+
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued Date
SOURCE RE U TIONS. O r/ 2 /D
Re-roofs
Signature of Applicant/Contractor Date
HAZARDOUS MA ALS DISCLOSURE Type of Roof
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)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes j1 N��
V If a roof is 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 defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yesre�
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,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
''�� of fi3 ""t All roof coverings to be Class'A•'or better
Owner or authorized agent k Date