07100047 / .
CITY OF CUPERTINO �����������������+
BUILDING DIVISION pERNIIT ;:: '
, . >. .:.: . .
::
BUILDING ADDRESS: PERMIT NO.
10343 MENHART LN TBD - �.'0 BE DETERMINED 07100047 .
PERMTf LSSUE DATE
lER'S NAME:
SANJAYA BASNAYAKE � 11/13/2007
SAMTARY NO. CONIROL NO.
PHONE:
BUiLDING PERMITINFO
ARCHI'IECT/ENGINEER:
HLDG ELECT PWMB MECH
0 � 0 0
a p � UCENSED CONTRACTOR'S DECLARATION JOb DeSCflptlOil
u� (�yy �� �a� I am liccnscd undcr provisions of Chapur 9(commcncing
� z � wi�h Scction 7000) of Diviaion 3 of thc Busincst and Profcssions Code and my licensc is DEMO 1 S T 0 RY S F D
�� y in full force and effttt
v� Z Licenac Clau L�. �
; F p Datc Contractor
t � � ARCHI7'ECl"S DECLARATION
�t I undcrstanJ my plans shall be wcd u public rccords
�yU
� u. f' Liccnsed Pn�fessianai
� y � OWNER-BUILDER DECLARATION
t hereby nf[irtn �hat 1 am exempt Gum 1he Conuactars License Law for thc
� p o following rcason. (SccGon 7(Y31.5, Busincss md Profcssions Cadc: Any ci�y or county
y� Pi which requims a pcnnit w consuuc� alur. impmve. dcmolish. or �e�wir any suucwrc
prior W i�c issuance, also mquims �c applicant for such permil to file a signed stamment
_< thai Nc is liccnsc d pursuan t to i h c pmvi si o n s o f t h c C o n u a c t o r' s L i c c n s c C a w ( C h a p t c r 9 S q. F t. Floor Area Valuation
� t- �(commenring wi�h Scction 7000) of Division 3 of Ihc Busincss and Profcuions Codc) or � 1 � � � �
y �_. that he ia exempt theretrom md ihe bssis Cor t6e illegcd eumpuon. Any violadon of
Secdon 7031.5 by arry applicant for a permii subjecu �he applicant W a civil penalty of 3 7 515 0� 0`�� Number Occupancy Type
not more than fiw dund�ed dollars (5500).
❑ I. u owner of tlie pmpaty. ar my cmployces with wages as their solc compensatlon.
will do �he wark. u�d �he swctwe is notintended or offered forsale (Sa.7044. Businesa Re uired Ins ections
and Professions Code: The ConuacWr's License Law dces not app�Y to a� ov�'ner of 9 p
property who builds or improves �heceun, and who does such worlc himselt ar through hia
own employxs, provided that such improvemen�s ue not in�ended w otfered Cor sale. If,
however, the building or impmveme�t ia suld wi�hin one year o[ compkbon, �he owner-
builda will have lhe burden nC proving lhat he did not build or improve [or purpose of
sak.).
❑ I. u owner o[ che propeny. am exclusively conuuting wiih licenud rnnuactors to
cormtmct che pmjea (Sec. 7044. Businas and Professions Code:) The ConUacwr's Li-
cenx [.aw dau not apply to an ownu of propeny who builds or improves themon, and ,
who convacls for such projec�s with a convactor(s) licensed pursuant to �he Convactor's
License Law. , B& P C for this roason
'""� I am exempt under Sec.
.�er y� i! r�f 7A7A �� S� AY A 1/�'E Date �( « a
WORKER'S COMPENSATION DECLARATION
I hereby �rm under penalty o[ perjury onc of the follawing declsntions:
❑ I hs.�e and will mainuin a CeniGcale of Consent to aelf-insure for Workcr's Compen-
sarion, ag provided for by Secuon 3700 of ehe Labor Code. for the performance ot the
work [or which Ihis pertnit is issued.
❑ I have and will muntain Warke(s Campensatian insunnx, u required by SccGon
3700 of �he Labor Code. Cor the peeformance o[ the worlc for which �his permit is issued.
My Worker's Compensation Insutance carricc and Poliry number am:
Carrier. Policy No.:
CER17F[CATE OF EXEMP170N FROM WORKERS'
COMPENSA710N 1NSURANCE '
(This sectian need not bc completcd i( the pecmit is for onc hundred dollars (S 100)
or Icss.)
1 cenify �h¢t in t6c performancc of tl�c work fw which �his permit is istucd. I shall not
employ any person in my manncr so u ta becam� mbLCCt w �he Workcrs' CompensaUon
Laws of Califomia Daic 11 � s o�
Appucan� ��•. ti? A YA /rP ••l h7i /k 1.c t _
Naf17CE TO APPLICANT: If, aMr making Ihis CertiGcatc of Excmp6on, you should
become subject �o Ufe Worlce�s Compenssuon ptovisions of We Labor Code, you must
� O fonhwith comply with wch provisions or this pecmit shall be decmed ecvoked.
Z ' " CONSfRUC170N LENDING AGENCY
(- � 1 hcmby aCCirm that thcro is a conswction Icnding agcncy (or thc perfwmancc uf .
p+ � Ihc work for which �his permit is iuued (Scc. 3097. Civ. CJ
W� Q L.endcfs Namc
l.cndet's Address
V 0 1 certify Ihat I have resd �his spplication and sutc that Ihc abovc infamatlun is
w � cortccL 1 agrce to comply wi�h all rity and counry ordinances and sute Iaws relaung to
0 U building conswction, and hercby auihori�s reprcsenutivcs of this ciry w entcr upon ihc
� W above-mcn6o�d pmperty for inspectiaa purposes
a (Wc) agree io ssve, indcmnify and kecp hannless ihe Ci�y of Cupertino against
„H,� � liabilitiea,judgmc�ts, cosLS and expenscs which may in any way acccuc against said City
V`� in consequencc af �c granting of this permiG Da[e
�" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PO1NT Issued b �:
SOURCE REGULATfONS.
o t 5��..Y A g� s N ��� � Re-roof:
Signaturc of Appliant/Conuxtor �a� T of E�oof
HAZARDOUS MATERIALS DIS OSURE }r�
Wip Ihe applicant w futurc building acupaet storc or handlc ha•rardous ma�crial
�cfined by the Cupenina Municipal Codc. Chapicr 9.12. and thc Hcalth and Safcty
.�. Scction 25532(a)T All roof:: shall be inspected prior to any roofing material being installed.
❑Ycs ❑No
If a roof is installed without first obtaining an inspection, I agree to remove
Will �he applicant or future building accupant use equipment or devices which '
cmit harardous air conwninan�s u dcfincd dy the Bay Arca Air Quality Managemcn� all new i naterials for inspeccion
District?
� Ycs ❑ No
1 havc rcad ehe ha�arda+s mamrials requiremen�s undcr Chaptcr 6.95 of Ihe Califor•
niaHcalih&SafetyCodc.Sections25505.25533and25534.1undcrsundtiutiCthe 6uildin6
dacs not curtcnlly havc a mnant, ihat it ia my responsibility to noufy the occupant of Ihe
rcyuiremcn�s whicd must be met prior to iuuancc of a Ccni f atc of Occupancy. S1gIldtllr � of Appl icant Date
�� S�r,., gks..rhv�� � S � ` All roof coverings to be Class "B" or better
Owncr or authori�ed agcnt