12110057CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7557 LOCKFORD CT
CONTRACTOR: AFFORDABLE WATER
PERMIT NO: 12110057
11 EATERS R
OWNER'S NAAM SHOBANA RAGOTHAMAN
28372 CONS ELLATION RI)
DATE ISSUED: 111092012
OWNER'S PIIONE: 4085170459
VALENCIA, CA 91355
PHONE NO: (661)259 -7131
❑ _ LICENSED CONTRACTOR'S DECLARATION
r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. H
r r
AIECH RESIDENTIAL COMMERCIAL
Contractor Date
hereby allirm than am licensed under the provisions of Chapter 9
JOB DESCRIPTION: REPLACE WATER BEATER, SAME LOCATION
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
hereby ape rm under penally 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 die Labor Code, for the
performance of the work for which this permit is issued.
Sy. Ft Floor Area: 0
.
x'nluation: $_479
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
APN Number: 36226040.00
Occupancy Type:
permit is issued. , -
API'LICAN I' CE R'fI PIC.VI'ION
I certify that I have read this application and stale that the above information is
correct. lagree to comply with all city and county ordinances and state laws relating
PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction, mid 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 of Cupertino against liabilities, judgments,
180 DAYS FROM LAST CALLED INSPECTION.
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
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 witho i first obtaining an inspection, I agree to remove all net materials for
hereby affirm that 1 am exempt from the Contractor's License Law for one of
inspection.
the following two reasons:
.
L as owner of the 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)
I, as owner of the property, am exclusively contracting with licensed contractors to
ALI, ROOF COVERINGS TO BE CLASS "A" OR BFITER
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
I IA"l,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 S Safetv Code, Sections 25505, 25533, and 25534. I will maintain
Compensation, as provided for by Section 3700 of the labor Code, for the
compliance wish the Cupertino Municipal Code. Chapter 9.12 and the Ilealth &
performance of the work for which this permit is issued
Safely Code, Section 25532(a) should.) store or handle hazardous material. "
I have amid will maintain Worker's Compensation Insurance, as provided for by
Additionally, should 1 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 M the Bay Area Air Quality Mnnagement District 1 will
maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the
permit is issued
Ilealth & Safely Code, Sections 25505. 25533. and 25534.
1 certify that in the perfomance 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
Owner or authorized agent: '
Compensation laws of California. If, after making this certificate of exemption, I
Dale:
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.
CONSI'RUCt'ION LENDING AGENCY
'
I hereby affirm that there is it construction lending agency for the performance of swrk's
APPI,ICANI' CER'I'IFICA "1'ION
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 stale 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
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
ARCHITECT'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