12060035CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 834 SEPTEMBER DR
CONTRACTOR: VILLA PLUMBING
PERNIff NO: 12060035
OWNER'S NAME: A13I1AY ACIIAREKAR & NIRUPAMA PUJARE
1590 LANA \\'Al' SfE 5
DA'Z'E ISSUED: 06/06/2012
OWNER'S PHONE.: 4082577919
IIOLLISTER. CA 95022
PHONE NO: (408) 848-4102
❑ LICENSED CONT'RACTOR'S DECLARATION
r r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. 0
MECH RESIDENTIAL COMMERCIAL
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: REPLACING 50 GALLON WATI7R HEATER
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and eRcet.
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certilicale of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance Of the work for which (his permit is issued.
Sq. Ft Floor Area: 0
Valualion: $750
1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for (he performance of the work for which this
permit is issued.
APN Number: 36214020.00
Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City ofCupertino against liabilities. judgments.
I80DAYSFROMLASTCALLEDIN$PECTION.
costs, and expenses which may accrue against said City in consequence of the
granting of this perrnil. Additionally, the applicant understands and will comply
with all non -point source reguladats per the Cupertino Municipal Code, Section
Issued by: Date:
9.18.
Signature Date
RE: ROOFS:
❑ OWNER -BUILDER DECLARATION
All roofs shall be inspec(ed prior to any roofing material being installed Ifa roof is
installed without first obtaining an inspection, I agree to remove all new materials for
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
inspection.
the following two reasons:
1, as owner of (he property. or my employees with wages as their sole compensation,
Signature of Applicant: Date:
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the properly, am exclusively contracting with licensed contractors to
ALL ROOF COVERINGSTO RE CLASS "A" OR BEITER
construct the project (Scc.7044. 13usiness & Professions Code).
I hereby affirm under penulty of perjury one of the following three
IIAZARDOUS MATERIALS DISCLOSURE:
declarations:
I 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 Cade, Sections 25505, 25533, and 25534. 1 will maintain
Compensation, as provided for by Section 3700 of the Labor Code, for the
compliance with the Cupertino Municipal Code, Chapter 9.12 and the I Icalth &
performance of (he work for which this permit is issued.
Safety Code, Section 25532(a) should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance, as provided for by
Additionally. should I use equipment or devices which emit hazardous air
Section 3700 of the labor Code, for the performance of the work for which this
contaminants as defined by the Bay Area Air Quality Management District 1 will
permit is issued
maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the
Ileallh & Safety Code, Sections 25505, 25533, and 25534.
1 certifythat in the performance of die work for which this permit is issued. I shall
not employ any person in any manner so as to become subject to the Worker's
Owner or authorized agent:
Compensation laws of California. Il', after making (his certffca[e of exemption. I
Dale:
become subject to the Worker's Compensation provisions of the Labor Code, I must
fonhwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION [.ENDING AGENCY
I hereby affirm that there is a construction lending agency for the perf'or lance of work's
APPLICANT CERTIFICATION
for which this permit Is Issued (See 3097. Civ C.)
I certify (hat 1 have read this application and state that the above information is
Lender's Name
cored. I agree to comply with all city and county ordinances and state laws relating
to budding 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 brainless the City of Cupertino against liabilities, judgments.
costs, and expenses which may accrue against said City in consequence of the
,\RCIII'f F.(T'S DECLARATION
granting of [his permi(. Additionally, the applicant understands and will comply
I understand my plans shall be used as public records.
with all non -point source regulalims per the Cupertino Municipal Code, Section
9.18,
Licensed Professional
Signature Date