07090097 I CIT�' OF CUPERTINO ' ' ` �p
BUILDINGDIVISION PERMIT ��������`�'���������*
>.: . . :::
, :.
;, _, .:: .
pERM1T NO.
BUILD a � c �� ESS COLUMBUS AVE TBD - T�� BE DETERMINED 0 7 0 9 0 0 9 7 .
PERMTT LSSUE DATE
R'S NAME: .
PRATIVADI K. 10/16/2007
SANITARY NO. CON'IROL NO.
PHONE:
BUILDING PERMIT [NFO
ARCHITECT/ENGINEER: BLDG ELECf PLUMB MECH
� � � �
i p p UCENSED CONTRACI'OR'S DECLARAT[ON IOb DeSCT1pIl0(I
� v� ( Mscby affirm that I arn licenscd unJcr provisions oC Chaptcr 9(commencing
; Z� withScction700U)ofDivision3ofiheBusincssandPrafcssionsCode MASTER 3EDROOM EXTENSION(341 SQ� , ADD FULL BA &
> j y in full Corcc and efc«� WORK SH �P (116 SQ �.
� v� z Licensc Class Lic. #
� p Conitactor
: F � ARCHiTECI'S DECLARATION
j a .�
a 1 undcrstanJ my plans shalt Ac uscd as public records
)aU
' w y Licenscd Pmfessional
. � a OW NER-BUILDER DECLARATION
� a� 1 hcrchy a1Trm �hat 1 am cxcmpt Cmm tLc Contractor's Liccnsc Law for Uic
L p o (ollowing mason. (Scc6on 7031.5, Busincss and Profc.csians Calc: Any city or county
�,°, � which requires a pctmit to conswct, altcr, improvc, dcmolish, or rcpair any suuctucc
°" y prior �o i�s issuancc, alsa rcquires thc applicanl for such pertnit to filc a signcd sta�mcnt ��. Ft. Floor Area Valuation
-?< �hat he is licensed pursuant to thc provisions oC thc Contracwr's Liccnsc Caw (Chapux 9 `>q � 5 O O O O
r F� (commcncing wiih Scction 7000) of Division 3 of ihc Busincss and Profcssions Codc) or
��� ihat he is exempt the�cfrom and Ihe basis far t6e allcgcd exemption. Any violatlon o[
Secuon 7031.5 by a�ry applicant [or a permic subjccts �he applicant to a civil penalry af 3 6 2 0 4 012 �� Number Oeeupaney Type
noi more t h a n f i v e h u n d re d d ollars (SS00).
❑ I, az owncr oC tt�e property. or my employces with wagu as the'v salc compensatian,
wiil do thc work, and ihe structuce is not intendcd or oftered forsale (Sec.7044, Business Required Inspections
and Pcofessions Code: llu Conuacmr's License Law docs noe apply tn an owou o�
propeny who builds or improves Ihercon, and who docs such work Aimsel[or Ihcougti hit
own employces, providcd that such improvemenls are not intended orallered forsale. l[.
however. the building or improvement is sold within one year of wmpte6on, i6e owneo-
buitder will have the burden oC proving tha� hc did not build or improvc (or pu�pose a[
sal ).
I, as awner of the property, am exclusivtly convacting with licenxd rnnuactoes �o
truct the projm (Sec. 7044. Business and Protcssions Cade:) The Contracwrs Li-
cense Law docs oot apply w an owner o( propeny who builds or improves themon. and .
who convacts for such projects with a con�ractor(s) Iicensed pursuant to ihe Contrutors
License Law.
❑ I am uqmp under Sec , B& P C for �his reasoa
T Date L��� _. . _
M ENSATION DECLARA170N
1 reby affi under penalty ot perjury one o[ �he fallowing declarations:
❑ I hsve and will mainiain a CertiGcate of Conscm to self-insure for Workers Compen-
sation, as provided for by Sec[ion 3700 of the Labor Code, for the performance ot the
work (or which Ihis permit is issucd
❑ I havc and will mtintain Workcr's Compensation Insurance, ac icquired 6y Section ,
3700 of thc Labor Codc. Car thc pccformance of the work for which �his permit is issued.
My Worke�s Compensa�ion Insurance cartier and Policy number ue:
Cartier. Poliey No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section necd nat be complctcd if the pertnit is for onc hundred dotlazs (5100) .
or Icss.)
I cenify thct in thc perf a cc of thc work for which Ihit pertnil is issucd. 1 shall not
employ any person in an ncr so az to bcrnmc bjcct ta Uu Workcrs' Compcnsatia�
Laws of Califomia. Da
Applicant
NOTfCE TO APP , a � eniticatc of ExcmpGa
bccome subjcct m thc orker's Co pensation provisions of the Lal�or C you must
, z forthwith cpmply with such prav'u' ns or this pccmi� shall bc dccmcd mrokcd.
z O CONSfRUCT10N LENDING AGENCY
(.~-� � 1 heroby aRrm �hat thcrc is a conswction Irnding agcncy for thc perfwmancc of
�Y„ � Ihc wurk fur which lhis pertnit is issucd (Sa:. 3097, Civ. C.) ,
W Q Lendcr's Narnc
� z L,cnder's Address
V � I ccrti(Y ihat I havc rcad this application and statc that thc abovc infortnation is
�� correct. 1 agree �o comply with all city and county ardinances and state laws rclaung w
� U building conswction, and hcreby authati�e reprcsentativcs of ihis city to cmcr upnn thc
� W ahovrmcntioncd property for inspccuon puqwses.
a (Wc) agrce to save, indcmnify and kecp hartnless thc Ci�y o( Cupcnino againsi
�� liabil' 'u, ' dgmcnls, cosls and expenses which may in any way acccuc against said ��y
V z in co seq nce oC tAe gnnung o( Ihis permit. �
� AP IC NT UNDERSTANDS AND ILL COMPLY WITH ALL NON-POINT Issued by: Date ` ,�l �
SO R E L TIONS. �
Re-roofs ���
� � ARDOU MATERIALS DISCLOSURE D � Type of P.00f
Will ihe a licant or futurc building occupant storc or handlc •ardous ma�crial
lcfincd by thc upenino Municipal Cadc. Chaptcr 9.12. and thc Hcal�h and Sa(ety
�, s��o� z 32(a)? All roofs shall be inspected prior to any roofing material being installed.
� y� �No .
WIII thc applicant or fu�urc building occupant usc equipmcnt or �icc� whieh
If a roof is installed without first obtaining an inspection, I agree to remove
cmi� hvardous air conwminan�s u dcfincd 6y the Bay Area Air Quality Managcmrnt all new rr �aterials for inspecr.ion.
Disuict?
❑ Ycs �No
I havc maJ U�e ha�ardous ma�erials requircmcn�s undcrChap�cr 6.95 af the Califor-
nia Hca & Safcty Codc, Sections 25505.25533 anJ 25534. ( undcrstand ihu iCdre 6oi�d�n6
d t cu t�y havc a tcnan6 ihat' my rcsponsibiliry to notity Uu a:cupant of ihe
rc u' mcn�s hich must bc me� prior't issuan f a Ccnifica�c of P Signature of Applicant Date
All roof coverings to be Class "B' or better
wn or aut .ed agcn �