08010118 (3) CITY OF CUPERTINO
BUILDING DIVISION PERMITMhCONT11 RACTOR INFORMATION,
PERMITN0.
BUILpIbtCrvAA
TEIENHART LN SANJAYA BASNAYAKE - 08010118
OWNER'S NAME: M PERMTT ISSUE DATE
SANJAYA BASNAYAKE 10343 MENHART LN 01/31/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHTTECT/ENCINEM BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�Op LICENSED CONTRACTORS DECLARATION Job Description
d wi g 1 hereby affirm,that I ant licensed under provisions of Chgw 9(commencing P
n<Nmath Section 700il Of DiAtion 3 offt Bowness and Pcofe Cnde.and my tieusse is DEFERRED SUBMITTAL TRUSS CALCS,ORIG #07090036—NO
n full fora end ellen.
Llcmmclau Lic.d NEW PERMIT
n F, Dane Coruaew
££
ARCHITECTS DECLARATION
eW 1 understand my Plans shall he used ex public would.
U
O Licertse0 Pmfessianal
OWNER-BUILDER DECLARAnON -
.� f I hereby of tum u sl I em exempt from be Contranora Lieanae Law for The
_
no trlfowing roman.(Scetion 7031.5.Business and Profemons Code:My city or county
u S F which requires a Permit to crmwct,abet.Impmnamm
,dollth, repan
air y sommre
i< prior W its issuance,also sequins the appiiram for such permit W rile a signed statement
szc that he is lustre puruunt to the provisions of the ConumWrs I A—Law(chapa9 Sq.Ft.Floor Area $O Valuation
ser t-$ (commencing with Srtion TODO)of Division 3 of to Business was professions Code)or
i - that he is exempt therefrom and Oe basis for the alleged exemption My violation of
Section 7031.5 by nary eppiimt for.permit subjects the"Plirsnt W a e1vU penally of
reanriNbOT tmarethvehorthnddollws(s50m. 37515040 Number Occupancy Y YPe
0 1,as owner of the property.or,my employees with wages u duck sole rmmPensau...
will do the wort and time munure u not intended Or o@tnd for sale(See 70th,Business
and professions Cade The CnnuacWr's Licmm Law doe oat apply W an owner of Required Inspections
property who twitcher,imptow Thereon,and whodoes such workhWulforthmugh his
own employees,provided thuauch impmnmersts are not intended mo@seed for sals.U.
hawew.de Wilding or impmwoent is mid within one year afemapled(mthe owner-
builder witi have the burden of pmving Nat M did not build of improve for Purpose of
sale.).
fa'1.as owner of the Property.am exclusively conuwing with licensed MMMMMa W
construes the project(Sec.7044,Buira and PMICUMM Code:)Tine rDOUact+ U-
room Law does not apply W an owner of property who builds of imProvea thereon,and,
who conuav fm such projects with a eamMoOKS)licensed pur Mthe contractors
IJCCR4 L.W.y
0 lconexcroprundes Sec //JJ .B APC fa this rescan
Owner 1" S'9 Nrt Ya(T� UDue C�L }I J
WORKER'S OMPENSATIOND TION
1 hereby air.nmder penalty of perjury ore aI the foluming dxW Wmm..
1 here and wtR munuin a Certificate o(Co"a"•W u3f-inure forwmkers Compere
tion,as Provided for by Scolon 3700 of the Labor Code.fol Ne performance of the
wort for which Oats permit is issued.
0 1 have and will maintain workers Compensation Insurance,u required by Sccdm
37DD of the Tabor Cade,for is pcdarmince of the work for which thus permit Is Issued.
My workrri com,coutioo hmuance carrier and Policy number con
Cartier. Policy No_
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thus section need not he compincd if the permit is for ane hundred dollars(SIOM
mita)
1 certify that in tae Pcfforouaoa of the cork Ifo which this permit is issued.I IUI am
employ any person in any manner m u to bemme mbjcot In the Workers'ComPuuauan
La..of California.Dau
Applicant F..._ <.
NOTICE TO APPUCANT:If.after making this Cenifnean dfF_sonption,you should
become subject W thc Wnrters Compcwtion provisions of the Isbm Cods you most
.J Z forthwith comely with such prod.ur this peanit"I he droned revoked.
zCONSTRUCTION LENDING AGENCY
Ihenb,.ITm thatther,uacmuuucton lmdogagemy forthcpedermutcoat
p' the work for which than Permit Is issued(SM,3097.Civ.Cal
yA Isnders Name -
,Z Lenders Address
U O 1 certify,that I ban and this apPliaion and ante than the theme information Is
u, F Correa 1 agree W Comply with all city and county Ordinances and mate laws missing W
O U building construction.and hereby BUNarine MpMMrIMxwj of that sty W color upon the
abort-mentioned Property for inspection Purposes
(We)agree to save,indemnify and trap handless the City of Cupertino agues
W liabilities,judgments,coats and expense which may in any coy seers,against said City
U Z in emuequena of de Starting of this pemic
'-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. /(�
Fy fL S g/rS N)Cy/S- till ti L7 `V31A C Re-roofs
Signmm o(AppliontConumWr L Hato
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant same or handl,hmNOW material
u defined by the Cupertino Municipal Code.Chapter 9.12 and the Health and Safely
Code.Section 25333(.)7 All roofs shall be inspected prior to any roofing material being installed.
S Yes t g s.
Will the applicant or future wilding occupant use tquMMcm or d,vlm which If a roof is installed without first obtaining an inspection,I agree to remove
emit huardnu air contaminants as defined by the Bay Ana Air Quality M...g,mcm all new materials for inspection.
mucic"
Oyu {�7 No -
I haw read the hares.uraWrissrol mmunts under Cha umli.95af Oe Califm.
nia Hrai"SafnyCode,Srtsiom 255(15.75533 and 25534.l usicasnd thatifte Wldmg
dors out cumntiy haw a WnM4 that it u my marfondbility Is badly Oe occupant of the
rtyuirtmen C2h usthemetpriorWissuarccof Ccrallexcaf0ecvpwwy. Signature ofApplicant Date
S c'ak�'a�-z All roof coverings to be Class"B"or better
Owner or Bwhmifad sg,nt DOW
C u t
CITY OF CUPERTINO
I OF
CUPEQ INU REVISION/DEFERRED
PERMIT APPLICATION FORM
APN # Date:
-7 130 bill �Jog.
Original Permit #: p 7 0.9 p o '36
Building Address: j p 3 43 M E M ^c-2T L �i
Mailing Address (if different from-building address):
Owner's Name: S Fc�l �.�7 A Phone #:
b � A 4 a 9 373 6 3 4 8
Contractor: Phone:
Ho Fax:
Contractor License #:
Cupertino Business License.#:.
Contact: Phone:
CH /\-D MA-IL7ir-J Alvev7.N •SAO" fl-A 1 209 464 7355
Fax:
Building Permit Info:
Bldg ❑O Elect ❑ Plumb ❑ Mech ❑
Residential Cominbrcial El
Job Description: e-(c--r
b
Type of Construction-(Usage Class): * Occupancy Type:
1 FR, 11FR ❑ 11, 111, V-IHR ❑ 11, 111, iV V-N [ — 2 3
Valuation (cost of project):
Project Size: Standard arge. Major ❑ Valuation: