11060196 (7) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18970 NEWSOM AVE CONTRACTOR:SAMPAT SHAILESH& PERMIT NO: 11060196
BHAVNA TRUSTEE
OWNER'S NAME: SAMPAT SHAILESH&BHAVNA TRUSTEE 7181 STOESSER CT DATE ISSUED:08/31/2011
*VNER'S PHONE: 4089276631 SAN JOSE,CA 95124 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMITINFO: BLDG ELECT PLUMB
License Class_ _ Lic N __ _
MECH F RESIDENTIAL r COMMERCIAL,
Contractor Date---
I
ate _1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REVISION#I-REVISE M.BATFI LOCATION.ADD
(commencing with Section 7000)of Division 3 of the Business&Professions FRONT WINDOW ON 2ND FLOOR CONSTRUCT'(2)STORY SFDWI.
Code and that my license is in full force and effect. 2,550 SQ FT W/ATTACHED GARAGE,406 SQ FT-SANITARY IS
SUNNYVALF.'S.IURISDICTION
hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Workers
Compensation,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 provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$300000
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information isAPN Number:37 35014 00 Occupancy Type:
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
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18 rLA
180 DA S FROMCALLED INSPECTION.
�t1
Signature _Date Issued by: ` �i Date:
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed If a roof is
1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection, I agree to remove all new materials fur
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code) Signature of Applicant:_____
1,as owner of the property,am exclusively contracting with licensed contractors to b pp _ Date
construct the project(Sec.7044,Business&Professions Code).
1 hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
1 have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should 1 store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued,1 shall contaminants as defined by the Bay Area Air Quality Management District 1 will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. I1',after making this certificate of exemption, I Health&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code, I most Owner or authorized agent:
i 1 i
forthwith comply with such provisions or this permit shall be deemed revoked Date: `
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
1 certify that I have read this application and state that the above information is
I hereby affirm
correct. I agree to comply with all city and county ordinances and state laws relating that there is a construction lending agency for the performance of work';
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec 3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
uld,mnify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the Leader's Address
.ung of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
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��` I understand my plans shall be used as public records.
Signature Date r
1 Licensed Professional