11080003 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10566 SANTA LUCIA RD CONTRACTOR:BG CONSTRUCTION INC PERMIT NO: 11080003
OWNER'S NAME: RAJIV&SUDHARANI PENDYALA 850 W SUNSET BLVD DATE ISSUED:08/01/2011
OWNER'S PHONE: 6504385084 HAYWARD,CA 94541 PHONE NO:(510)432-6249
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
TEMPORARY POWER POLE
License Class ElLic.# C!� C) S �r
Contractor J)pu Date 9—
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
Sq.Ft Floor Area: Valuation:$2000
1 hereby affirm under penalty of perjury one of the following two declarations:
1. 1 have and will maintain a certificate of consent to self-insure for Worker's APN Number:34216039.00 Occupancy Type:
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this PERMIT EXPIRES IF WORK IS NOT STARTED
permit is issued. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
APPLICANT CERTIFICATION 180 DAYS FROM LAST CALLED INSPECTION.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter Issued by: Date:
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and kee harmleaa the City of Cupertino against liabilities,judgments,
costs, penses which may accrue agams ity in consequence of the
gran g of this permit. Additionally,the applicant understands and will comply with RE-ROOFS:
all non oint so regulations per the Cupertino Municipal Code,Section 9.18. All roofs shall be inspected prior to any roofing material being installed. If a roof is
cod�e p� installed without first obtaining an inspection,I agree to remove all new materials for
Signature -�- ----�--- Date inspection.
Signature of Applicant: Date:
❑ OWNER-BUILDER DECLARATION ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
by affirm that I am exempt from the Contractor's License Law for one of
ti.-.Alowing two reasons:
1. 1,as owner of the property,or my employees with wages as their sole HAZARDOUS MATERIALS DISCLOSURE
compensation,will do the work,and the structure is not intended or offered for I have read the hazardous materials requirements under Chapter 6.95 of the
sale(Sec.7044,Business&Professions Code) California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
2. I,as owner of the property,am exclusively contracting with licensed contractors to compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
construct the project(Sec.7044,Business&Professions Code). Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
I hereby affirm under penalty of perjury one of the following three declarations: contaminants as defined by the Bay Area Air Quality Management District I will
i. I have and will maintain a Certificate of Consent to self-insure for Worker's ma' nce wi ertino Municipal Code,Chapter 9.12 and the
Compensation,as provided for by Section 3700 of the Labor Code,for the TIlealth&Safety Code,Sections 25505,25533,and 25534.
performance of the work for which this permit is issued. r authorikd agent:
2. I have and will maintain Worker's Compensation Insurance,as provided for by __ r,Date: �2�
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
CONSTRUCTION LENDING AGENCY
s f certify that in the performance of the work for which this permit is issued,I shall
I hereby affirm that there is a construction lending agency for the performance of work's
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I for which this permit is issued(Sec.3097,Civ C.)
become subject to the Worker's Compensation provisions of the Labor Code,I Lender's Name
must forthwith comply with such provisions or this permit shall be deemed Lender's Address
revoked.
ARCHITECT'S DECLARATION
APPLICANT CERTIFICATION I understand my plans shall be used as public records.
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating Licensed Professional
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply with
i-point source regulations per the Cupertino Municipal Code,Section 9.18.
Signature Date