12060042 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10978 NORTHSHORE SQ CONTRACTOR:AHORDABLE WATER PERMIT NO: 12060042
Ii EATERS&
OWNER'SNAME: BIIAVIRKAR GIRISH AND BHAKARE SUVARN 28372 CONSTELLATION RD DATE ISSUED:06/07/2012
OWNER'S PIIONE: 4087250631 VALENCIA,C\ 91355 NIONE NO:(661)259-7131
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.p
MECH r RESIDENTIAL COMMERCIAL
Contractor Dale
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REPLACE 50 GALLON WA I I[R I IEATIX SAM[:LOCATION
(commencing with Section 7000(of Division 3 of the Business&Professions
Code 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 will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
perfommnce of the work for which this permit is issued. Sq.Ft Floor Area:0 Valuation:$2462
1 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:31638017.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read[his 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. 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses wvhich may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18.
Signature Date
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed If a roof is
installed without first obtaining an inspection.I agree to remove all new materials for
I herebyaffirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons:
I,as owner ol'the property,or my employees with wages as their sole compensation, Signature of Applicant: Dale:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to ALL,ROOF COVERINGS TO BE CLASS"A"OR REITER
construct the project(Sec.7044.Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three ILA7-ARDOUS 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&Safely Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cuperlino Nlunicipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safely 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 critic Labor Code,for the performance of the 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
Ilealth&Safety Code,Sections 25505,25533,and 25534.
1 emit)that in the performance of the 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 this certificate of exemption,I Date:
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked CONSTRUCTION LENDING AGENCY
I hereby a1Trtn that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C-)
I certify that I have read this application and state that the above information is Lender's Name
correct. I 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
indemnily and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of ARCIIITF.CT'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 Date