12070206 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRLSS: 10650CARVFR DR CONTRAC`fOR:BETi'ER WATER HEATERS PERMIT NO: 12070206
OWNER'S NAME: 9'l l[RUMANDAS SURESI]AND SATI'OOR SU 3010 RIIIGF.GATE OR DATE ISSUED:07Q6f2012
OWNER'S PIIONE: 4082578047 SAN JOSE.CA 95133 PI ZONE NO:(408)250-6672
❑ LICENSED C0N`fRA(7f0R'S DECLARATION BUILDING PERMIT INFO: BLDG C ELECT r PLUINB
License Class Lie.H
i111ECH - RESIDENTIAL '" COAT M1IERCIAL
Contractor Dale
hereby affirm that I am licensed under the pr(n inions of Chapter 9 JOB DESCRIPTION:REMOVE AND REPLACE WATER HEATER IN THE SAME
(commencing with Section 7000)of Division 3 of the Business& Professions PLACE
Code and that my license is in full force and effect. 50 GALLON
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
performance of the work for which this permit is issued.
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 Sq.Ft Floor Area: Valuation:$1125
permit is issued.
APPLICANTCERTI FICATION APN Number:37532018.00 OccupaneyType:
I certify that I have read this application and state that the above information is
correct.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
upon the above mentioned propeny for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands mid will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Date.
Signature Date
❑ O\VNISR-BUILDER DECLARATION
RE. ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Lav for one of All roofs shall be inspected prior to any roofing material beimg installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or ollcred for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALI,ROOF COVERINGS TO BE CLASS^x'OR BETTER
hereby affirm trader penally of perjury one of the following three
declarations: IIA7.ARDOUS MATERIALS DISCLOSURE
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 I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued California Ilealth&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and Will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilealth&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code.Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Ilealth&Safety Code,Sections 25505,2.5.533,and 25534.
Compensationlaws of California. If,ager making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or authorized agent: '
forthwith comply with such provisions 2br this permit shall be deemed revoked Date:
CONSTRUC`T'ION LENDING AGENCY
A PPI ICAN"1'CERTIFICATION
I cenify that I have read this application and state that the above information is 1 hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances mid stale laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to sae
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may acerae against said City in consequence of the
granting of this permit.Additionally,the applicator understands mid will comply ,\RCIII'Ifh:CI"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional