12100172 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11772 PINE BROOK LN CONIRACfOR:STREET PLUMBING& PFRMIT NO: 12100172
ROOTER
OWNER'S NAME: SANGAMESWARA SIIANUBNOG G AND R 2293 WALNUI'GROVE AVE, DA'Z'E ISSUED: 1012312012
OWNER'S PHONE: 4085050545 SAN.IOSE,CA 95128 PHONE NO:(408)49&1155
❑ LICENSED CON'1'RACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.q r r_a r
- MECN RESIDENTIAL COMMERCIAL
Contractor Date
hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:NATER IEA'I'17R REMOVAL AND REPLACEMENT IN TI IE
(commencing with Section 7000)of Division 3 of the Business& ProfeS\hln\ SAME
Code and that my license is in full force and effect. LOCATION
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 Sq.F1 Fluor Area:0 Valuation:$500
permit is issued.
API'I.ICANI'CF.R'1'I17ICA'I'10N ANN Number:'36655033.00 Occupancy Type.
1 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 -
upontheabovementionedpropertyforinspectionpurposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep hardest the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence ofthe WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued b5': Date:
Signature Date -
❑ OWNER-RUILDER DLCLARAT'ION
RE-ROOFS:
I hereby affirm that 1 am exempt from the Contractor's License Lav for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without First obtaining an inspection.I agree to remove all new materials for
I,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 offered for sale(Sec.7044,
Business&Professions Code) Slgntnnre of Appficam: Dale:
1,as owner of the property,ten exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO IIF,CLASS"A"OR RET-fER
hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS 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 Labor Code,for the I have read the hazardous materials requirements tinder Chapter 6.95 of the
performance of the work for which this permit is issued. California Ilealth&Safety Code.Sections 25505,25533,and 25534. I will maintain
I have and will mainmin 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 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will
I certify that in the performance of the work fonwhich this permit is issued,l shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in tiny manner so as to become subject to the Worker's Ilealth&Safely Code.Sections 25505,25533,unit 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,1 must Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date'
CONSTRUCTIONS LENDING AGENCY
APPLICANTCF.RT'1 FICATION
1 certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.1 agree to comply with all city and county ordinances and state 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 save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCII ITECI"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