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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
6R1VIA'XION
BUILDING ADDRESS:
PERMIT NO.
7630 KIRWIN LN
ANILKUMAR SURPUR
06120113
OWNER'S NAME:
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT rNFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
P
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
REVISION SUPPORT DETAIL AT STAIRS
in full force and effect
:
License Class Lic-#
ORIGINAL PERMIT: 05110059
Da
Dale Contractor
ARCHTMCTS DECLARATION .
1 understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structum
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$ 3 2 3 0 5 5
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
ppppN Number
35922015. 0 0
Occupancy
P Y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (s500).
❑ 1, as owner of the propeny, or my employees with wages as their sole compensation,
Required Inspections
will do the work. and the structure Is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employers, provided that such improvements are not intended or offered for We. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).,---'.
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors U-
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractors) licensed pursuant to the Contractors
License Law.
❑ 1 am
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 hsve and will maintain a Certificate of Consent to self -insure for WorLWs Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued.
'
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed if the permit 1s for one hundred dollars (S100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner u torilCytbjecl to the Workers Compensation
Laws of California. Date — ���//
Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit Is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that 1 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 consuucdon, 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 in any way acme against said City
in COnaegOCnCC of the grantin Of t1iS permit.
DISCLOSURE
Type,of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Munici Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as d ned by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes No
1 have read the hazardous matcriais requirements under Chapter6.95 of the Califor.
nia Health & Safety Code, Sections 25505. 25533 and 75534.1 understand that If the building
does not c my have a tenant it is my responsibility to notify the occupant of the
'
.tegalre which must be m p' rto issuance of a Certificate of cr-
Signature of Applicant Date
a4
All roof coverings to be Class "B" or better
ae