12050017 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: I0134 IMPERIAL AVE CONTRACTOR:APPORDABLE WATIiR PERMIT NO: 12050017
HEATERS&
OWNER'S NAME: KAM1311AMPATI VENNGOPAL 24663 RAILROAD AVE DATE ISSUED:05/022012
OWNER'S PHONE.: 4082189688 SANTA CLARITA,CA 91321 PHONE NO:(661)259-7131
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Clercs Lic.N
MECH r RESIDENTIAL r COMMERCIAL
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE 50 GALLON WATER HEATER,SAME LOCATION
(commencing with Section 7000)of Division 3 of the Business&Professions
Cade and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and rill maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance ofthe work for which this permit is issued. Sq.Ft Floor Area:0 Valuation:$1500
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 APN Number:35722043.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct.I agree Io comply with all city and county ordinances and stale laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Igo DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of This permil. Additionally,the applicant understands and will comply
with all non-point source regulaliats per the Cupertino Municipal Code,Section Issued by: Date:
9.18,
Signature Dale
RF,-ROOFS:
❑ OWNER-RUILDF.R DECLARATION All roofs shall be inspected prior to any roofing material being installed If a roof is
installed without first obtaining an inspection,I agme to remove all new materials for
hereby affirm that I am exempt from the Contractor's License Law for one of inspection
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation. Signature of Applicant Date
will do the work,and the strucWre is not intended or offered for sale(Sec.7044.
Business&Professions Code)
h as owner ofthe property,am exclusively contracting with licensed contractors to ALL ROOF COV F.RINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
1 hereby affirm under penally of perjury one ofthe following three IIA%ARDOUS MATF-RIALS DISCLOSURE
declarations: 1 have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 ofthe Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the health&
performance of Ole work for which this permit is issued. Safely Code,Section 25532(a)should 1 store or handle hazardous material.
I have and will nminmin Worker's Compensation Insurance,as provided for by Additionally,should 1 use equipment or devices which emit hazardous air
Section 3700 ofthe Labor Code,for[lie performance ofthe work for Which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
health&Safely Code.Sections 25505,25533,and 25534.
1 certify that in the performance of the work for which this permit is issued,l shall
not employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation laws of Califomia. 11',after making this certificate of exemption,I Date:
become subject to(he Worker's Compensation provisions ofthe Labor Code,I must
forthwith comply with such provisions or[his permil shall be deemed revoked. CONSTRUCTION LENDING.AGF.NCV
I hereby alum that them is a construction lending agency for the performance of work's
APPLICANTCERTIFICATION for which this permit is issued(Sec.3097.Civ C.)
I certify(hal I have read this application and state that the above information is Lender's Name
coffee[.1 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 Lender's Address
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 accrue against said City in consequence of the ARCIIITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Licensed Professional
Signature Dale