11060196 (6) CITY OF CUPERTINO BUILDING PERMIT
wt ff Dl�c AI)DltEas: 18970 NEWSOM AVE CON't'ItAC'I'Olt: SAMPAT Sf IAILESFI PERMIT NO: 11060196
& BHAVNA TRUSTEE
f ft's vNiNi :: SAMPAT SHAILESH & BHAVNA TRUSTEE 7181 STOESSER CT DATE: ISSUED:08/31/2011
ms m-At's PL10NE.: 4089276631 SAN JOSE, CA 95124 PHONE NO:
❑ LICf:NSVD CONTRACT'OR'S DECLARATION
BUILDING PE:RMfT INFO: BLDG[ ELECT F- Pl,urytt3
rn;e l lai> Lic.N F- r r_
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�tecn IiEstot•:N"rtAt, co��lnl Is
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Date
- -- JOBDESCRIPTION CON S"f ftllCT(7)S'hORY SFDW1,2,5>0 SQ hl'W/r\1 1 ACTH
I tic,vbv atiirnt that I ant licensed under the provisions of Chapter 9 GARAGE 406 SQ F"I-SANITARY IS SUNNYVALE'S
(cunuuencinK with Section 7000)of Division 3 of the Business& Professions JURISDICTION
Codc and that nn license is in full force and effect.
I hcrehy affirm under penalty of perjury one of the following two declarations:
h;ne and will maintain a certificate of consent to self-insure for Workers
I ('1111en;auon-as provided for by Section 3700 of the labor Code,for the
I)cr!•lnnancc(it tire work for which this permit is issued. Sq. Ft Floor Area: Valuation:$300000
and will maintain Worker's Compensation Insurance,as provided for by
ru �,It()of the Labor Code. for the perfoinuutcc of the work for which this APN Number:37535014.00 Occupancy Type:
j �xtnlil i. iS�Ueil
V'I'LICAN"I•CERT►FICA'hION
.crti!� ut;u ! imnc read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
1c.i I aorec to comply v%ith all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
ii�ildin�s construction.and hereby authorize representatives of this city to enter
ul,00 the above mentioned property for inspection purposes. (We)agree to save 180 D YS FROM L CALLED INSPECTION.
ndcnmil and keep harmless the City of Cupertino against liabilities, judgments.
mid c\penscs��high may accrue against said City in consequence of the
Im_of this permit :Additionally.the applicant understands and will comply Issued by:
�ih;ill non-point;ounce rqulations per the Cupertino Municipal Code,Section
RE-ROOFS:
Date ________ All roots 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.
0\V NL•:R-1311- ILDER DECLARATION
Signature of Applicant._ Date:
I hereby affirm that I am exempt front the Contractor's License Law for one of
(It(,fnllurvin.hvu reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
n. Mmer of the property-or my employees with wages as their sole compensation,
ill do the%\ork.and the structure is not intended or offered for sale(Sec.7044,
& Plofcssions Code)
1 a,�Mller 0I the pmperty,am exclusively contracting"ilh licensed contractors to f1A"'/,ARDOUS MATERIALS DISCLOSURE
� n.0 uCi the pro!cct(Scc 70.14- Busmcss& Professions Code). I have read the hazardous materials requirements under Chapter 6.95 ol'the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hcrebv af7i1-In under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: health&Safety Code,Section 25532(a)should I store or handle hazardous
I ha\c and%�ill maintain a Certificate ofConsent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
'nIpCl1,;won-as piov ded lot by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District
ci Glrinancc of the work for which this permit is issued will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
ha rand "II maintain`I,\orkei's Compensation Insurance,as provided for by
the Flcalth&Safety Code,Sections 25505,25533,and 25534.
~colon ,00 of the Labor Code, for the performance of-the work for which this Owner or authorized agent:' Dater �\
henna i. usueil
cerin that in the perlor urge of the work for which this permit is issued.I shall
nen ciu!•!„� ;m� person in any manner so as to become subject to the Worker's CONSI'RUCTION LENDING AGENCY
, nihcn.;uion I:nc.of California- It,atter making this certificate ofexemption. I —
hc.onu .ubleet to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of
ith��uh omply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec 3097,Civ C.)
Lender's Name —
AI'PLIC:'\NT CG RTI FI CAT 1ON Lender's Address --
eiul that I have read this application and state that the above information is
regi I aerce to comply with all city and county ordinances and state laws relating
huildln"constriction.and hereby authorize representatives of this city to enter
c the tihove mentioned property for inspection purposes (We)agree to save ii,RClIlTECT'S DECLARATION
niney and keep harmless the City ol'Cupertino against liabllltIC$,judgments, -
❑rid expense which may accrue against said City in consequence of the I understand my plans shall be used as public records-
ienuna of this pernut Additionally,the applicant understands and will comply
,�ith all non-point source regulations per the Cupertino Municipal Code_Section I,icenscd Professional_
tiianauirc � Date