03060030 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT €CUI�TRACaTOI2T�NFORIVIA,TTIUN
BUILDINO ADDRESS: IT
INC y PERMNO03060030
11611 SEVEN SPRINGS DR
WNER'S NAME: 2531 GRACELAND AVE . PERMIT IllUFG`"3/2003
HERUVU SURYANARAYANA M AND V
TARCH1=10GINEER:
E: — SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
oEo �00uLICENSEDCONTRACIOR'SDECLARATIONJob Description
OnI1amDivimaanden REPLACE WATER HEATER ���w�C®
eCleuk.tJ !"� �in +tConuacbr
F 700700 S O RA O
?y< I deruaO PI ns Moll he uud u p mda r v
wV ' NOV 2 4 2003
;�S Licensed Professional
OW NE0.BUILDER DECLARATION
I I hcsehy of0rm Nn 1 am exempt from the Contractors License Isw for the
M 0following ression.(Sextion M 1.5.Business and Profession Code:Any City or county BUILDING
g V which¢,,mans a Permit to cnoamca.siloµImprove,demolish,at repair any tvuctum
�L^ prior ur its issuance.also requires the applicant for such Permit to file a signed statement
£� <
that he is licensed Pumintm Ne pmvisionof Nc Cmimalm's Linn.Li.(Chapter 9 Sq.Ft. Floor Area tion
y $ (commencing ction wish Se7000)of Division 3 ofthe Budnesaand Professions Code)or
..
that he isexempt tharefmm and the basis for the alleged exemption.Any violation of
Section 7031.5 by mr,applicant for a permit objects Ne applicant in a civil penalty of a Occupancy Type
not mare Nan five hundred dollars($500).
❑1,u owner Ofthe pmprny,or my employes with wages u their sole compensation,
will do tie work,and theauucu a Isnatietended or offered fonale(Sec.7044,Business
and limitations Cade:The COmlunur's LlRnm Law does not apply b in owner of 506 - GAS TEBgqulred nspecdons
propenywhobulldamImproves therwn,dndwhodauuchwork himselforlhroughhis 507 - FINAL PLUMBING
own employees,provided thatauch improvements are not Intended oraQelutl for sale.If.
homwr,the building or improvement is mid within one year of completion,the owner.
builder will have the burden of proving that he did not build or Improve for purpose of
ole.).
❑1.as owner of the property,am exclusively convecting with Ilaased conclusion to
construct the project(Sea.7044,Business and Profession Cade:)The Contracmri Lb
ane Law does not apply to an owner of property who Wilds or Improves thereon,and
who columna for such Project with a conuaclorD)licensed pursuant o the COnrscbrs
Liccnm Lew.
❑lam exempt under See .B k PC for ND moan
Date
WORKER'S COMPENSATION DECLARATION
1 hemby aflimn under pendly of perjury orte of she following deelaludon:
1 haw and will mainWn a Certifies ofConent to o15Luum for Workodt COmpen-
.Bars,o provided for by Section 37000f tie Gbor code.far the terfamunR clubs �I a•�
wag for which this permit is issued. I
1 low and will maintain Worker's Compensation Insurance,IS required by Section
3700.f the GborColic.per Ne performance Of the work Our which this permit is issued. '
My Workers Co n In nae arri[#W POI) num r arc:
Grria:
Policy No.:
CERTINCA OFEK PILON MUM WO KERS'
COMPENSATION INSURANCE
(This=).need Out be completed ifft permit is fdronc hundred dollars(SIM)
or leu.)
I amity Nat in the performance of the work for which this Permit is issued.I atoll net
employ any person in my mannerm u to become abject in the Workni Compensadon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:if.after making this Cenineau of Exemption,you should
become subject to the Worker's Compensation prevision of she Labor Code.you mum
0 fOMwiih comply wit such provisions or this permit Mall be deemed¢oohed.
Z CONSTRUCTION LENDING AGENCY
_H I hereby affirm Net Nem it a construction lending ageory for Ne performance of
the work for which this armit is InRd(Son.3097,Civ.C.)
W A Lenders Nmne
z Lentlers Add.
f,Q I certify that I hew mad Nis application and stets Net No about information is
W Fcorrect.I agree to comply with all city and county ordinances and amt lawn relating to
QUbuilding construction,and hereby northern representatives Of this city to enter upon one
W ahovo-memtionod property for lnspecdon purposes. f/ld/ J
y
(We)agree b caw,indemnify and heap harmless the Clay of Cupertino AgainstCity �y
n,t rq
liabilities,judgments,ill calm Inde penses nifyand keep
may inany tmy he
of
moid City
L)Z in consequence of the Stenting of this permit.
APPLICANT UNS,DERSTANDS AND WILL COMPLY WITH L VON-POINT Issued by: D to
SOU CUSATIO ///��77��,, ,
.r' _(a. (!/ U✓ Re-roofs
Si um of ApPUcaHAZA ter Deb
HAZARDOUS MATERIALS Occupant
slow hDE Type of Roof
Will the applicant or future building Oaupanc aim ar handlen mabrial
o denncd by ante Cuanino Muni IPJ Cade,GaPur 9Health.12,and the Health and Safely
ode.Section W32(4? All roofs shall be inspected prior to any roofing material being installed.
❑Yca Na
Will the applicant or future Wilding aceupam me equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hactuous air conuminmbof defiled by Ute Bay Area Air Quality Management all new materials for inspection.
District?
Yes
I have read the hvallow malerielsreyuiremenu under Chapterli.95 dime Glifor- r
ni.HRIN @ Safety Code.Sce ore 25505.25533 md2S534.I understand Nmifde building u.4
does not currently hew a unant.that It 4 my ouponihility in mtify th oaupant of the
mqu m uyryeq/ntumldmetpddr omccacerdfutea a Signature of Applicant Date
(%G ' All roof coverings to be Class"B"or better
Owner m authomsd agent D
CITY OF CUPERTINO D
i� WATER NEATER
CUPEKTINO PERMIT APPLICATION FORM
APN# 30,6 ,2o X3 Date:
Building Add 7,111
�h.
Owner's Nam : Phon
1ccr r 073 � -
Contrac Phone:, License#:
Contact:ah.i Phone: Cupertino Business License#:
�F
Building Permit Info:
Bldg ❑ Elect ❑ Plumb/ Mech ❑
Job Description:
Residential ❑ Commercial ❑
Cost of Project:
• Strapped ❑ On Platform ❑ Bonded ❑
New Location ❑ Replacement
Qty. if
A 1' a 1 Fee ID Fee Description Fee Grou
BPWHEATER Water Heater/Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
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