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11070195 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 1016 NOVEMBER DR CONTRACTOR:DG HEATING&AIR PERMIT NO: 11070195 CONDITIONING OWNER'S NAME: RAJARAM GIRIDHAR AND GANESH CHANDRI 2288 CHERRY AVE DATE ISSUED:07/26/2011 c :ER'S PHONE: 4085170750 SAN JOSE,CA 95125 PHONE NO:(408)978-1411 ❑ LICENSED CONTRACTOR'S DECLARATIONr n _> BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class �i D Lic.# C' Zy MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am license u er the provisions of Chapter 9 JOB DESCRIPTION:INSTALLING AIR CONDITIONER;ADHERE TO 5'SETBACK (commencing with Section 7000)of Division 3 of the Business&Professions TO Code and that my license is in full force and effect. PROPERTY LINE 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 permit is issued. Sq.Ft Floor Area: Valuation:$3695 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is APN Number:36215010.00 Occupancy Type: 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 property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED costs,and expenses which may accrue against said City in consequence of the granting of this pei Additionally,the ap licant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR with all non- oint soutce regulati pert upertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION. 9.18. l Signature Date �� 1 ( Issued by: Date: L OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS: the following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection. Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date: construct the project(Sec.7044,Business&Professions Code). I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER declarations: I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE 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 read the hazardous materials requirements under Chapter 6.95 of the I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health& 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. permit is issued. Additionally,should I use equipment or devices which emit hazardous air I certify that in the performance of the work for which this permit is issued,I shall contaminants as defined by the Bay Area Air Quality Management District I will not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Compensation laws of California. If,after making this certificate of exemption,I Healthale Code,Sections 25505,25533,and 25534. 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. Owner o thorized agent: Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY 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 and state laws relating I hereby affirm that there is a construction lending agency for the performance of work's to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.) upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name i• inify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may accrue against said City in consequence of the Lender's Address granting of this permit.Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional Building Department City Of Cupertino LM 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 CUPERTINO Fax: 408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: O `Q N c)V PERMIT# ! L OWNER'S NAME: L-"--> '-- PHONE# GENERAL CONTRACTOR: & ' w BUSINESS LICENSE # ADDRESS:Z2J58 �''s`/Z CITY/ZIPCODE: *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: 77 ignature Date Please check applicable subcontractors and complete the following information: V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/ Carpeting Linoleum /Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting /Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Signature Date 110-7 GENERAL PERMIT APPLICATION - MEP LM COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION 10300 TORRE AVENUE •CUPERTINO, CA 95014-3255 (408)777-3228• FAX(408)777-3333 • buildingl�DcuDertino.org MISC CUPERTINO ❑PLUMBING MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS PROTECT ADDRESS APN 51�9 — 0 OWNER NAME ! PHONE /��.,/y�`;7 __a E-MAIL STREET ADDRESS CITY, STATE,ZIP / FAX CONTACT NAME PHONE E-MAIL. STREET ADDRESS CITY,STATE, ZIP FAX ❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAMECEN ABER LITISE�E BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS n CITY,STATE,ZIP PHONEO G� ARCHITECTIENGWEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE JSE OF ❑SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN WII DLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ YES BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO DESCRIPTION OF WORK TOTAL VALUATION: 3 _ RECEIVED BY: By my signature below,I c �fy to each of the ]lowing: am the prop owner or authorized agent to act on the property owner's behalf. I have read this application and the infonnati have provide is corre I have read esc tion of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relao to building nstruc o `I authori r ves of Cu ertino to enter the above-identified property for inspection pod oses. Signature of Applicant/Agent: Date: 1 SUPP AL INFO ON REQUIRED OFFICE USE ONLY w ❑ OVER-THE-COUNTER o. ❑ EXPRESS U w ❑ STANDARD U ❑ LARGE ❑ MAJOR MEPMIscAPP_2011.doc revised 06121111