12090108CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1132 ELMSFORD DR
OWNER'SNAME: MAJUMDER SUM IT AND NEELANLWA
OWNER'S PIIONF: 4083937121
❑ LICENSED COYfRACFOR'S DECLARATION
License Class Lic.N
Contractor Date
hereby affirm that 1 am licensed under the provisions of Chapter 9
(commencing with Section 701111) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
1 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
permit is issued.
,O'1'LICAYI' CF.R'1'IPIC TION
I cenify 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
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned properly 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
granting of this pernit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Date
❑ OWNER-131111,DER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business R Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business R Professions Code).
1 hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Cenificate 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
permit is issued.
I certify that in the perfommnce of the work for which this permit is issued. I shall
not employ any person in my manner so as to become subject to the Worker's
Compensation Imus of California. If, afler making this certificate of exemption, 1
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.
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 mid state laws relating
to building construction, mid hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to sae
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which 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
9.18.
Date
CONTRACTOR: FAST WATER IWATER PERMIT NO: 12090108
12601132 AVF, NE DATE ISSUED: 09/122012
KIRKL.AND, ARA 98034 PHONE NO: (800) 454-8955
BUILDING PERMIT INFO: BLDG 1_ ELECT C PLUMB r`
M ECII r RESIDENTIAL r COMMERCIAL 1 -
JOB DESCRIPTION: REMOVE AND REPLACE WATER HEATER IN EXISTING
LOCATION
Sq. Ft Floor Area: 0 1 Valuation: $1603
APN Number: 36209021.00 1 Occupancy'I'ype:
PERMIT EXPIRES IF WORK ISNOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
RI: ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed withou first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALI, ROOF COVERINGS TO BE CLASS "A" OR RETfER
lh'/,ARDOUS MATERIA S DISCLOSURE.
have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth S Safety Code, Sections 25505. 25533, and 25534. 1 will maintain
compliance wish the Cupertino Municipal Code, Chapter 9.12 and the Health S
Safety Code, Section 25532(x) should I store or handle hazardous material.
Additionally, should 1 use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air QualityManagement District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Ilealth S Safety Code, Sections 25505. 25533, and 25534.
Owner or authorized agent:
Date:
CONSTRIICPION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ Q
Lender's Name
Lender's Address
ARCHITECI"S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional