10090086 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 792 MILLER AVE CONTRACTOR:MASTERSERV INC PERMIT NO: 10090086
OWNER'S NAME: SUREN PRAJAPAT 560 LIBRARY ST DATE ISSUED:09/13/2010
WNER' HONE: 4085058987 SAN FERNANDO,CA 91340 PHONE NO:(800)806-7674
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lie.# >
MECH RESIDENTIAL COMMERCIAL
Contractor CI-1/v Date
JOB DESCRIPTION: COPPER REPIPE REPLACE 10 FIXTURES
I hereby affirm that I am licensed under the provi�Ch
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
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. Sq.Ft Floor Area: Valuation:$7006
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 APN Number:37542006.00 Occupancy Type:
permit is issued. 4/�/
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgment,,
costs,and expenses which may accrue against said City in consequence of the Issued by: Date:
granting of this permit. Additi the applicant understands and will comply
with all non- urc gulatiohs er the Cupertino Municipal Code,Sectior
9.18.
RE-ROOFS:
Signat Date_ L All roofs shall be inspected prior to any roofing material being installed.If a roof is
` installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
It.06 101'
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for oiie of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,or my employees with wages as their sole compens:tion,
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 Iicensed contractor;to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the Cupertino,,Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sec' 5,25533,and 2§534.
Section 3700 of the Labor Code,for the performance of the work for which this; Owner or authorized a Date:�3
permit is issued.
I certify that in the performance of the work for which this permit is issued,I sl call
not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemptior,,I
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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
to building construction,and hereby authorize representatives of this city to en ter
anon the above mentioned property for inspection purposes.(We)agree to sav: ARCHITECT'S DECLARATION
Siemnify and keep harmless the City of Cupertino against liabilities,judgmer ts,
gists,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
Sep. 2. 2010 6: 51AM MasterServ, Inc. No. 1394 P. 2/4
CITE' OF CUrPERTINO
atct�o RIEPIPE/SEW ERIMAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
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APN# _ Date:
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BuildiAddress:
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Owner's ame: Phone#:
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Contractor: Phone#: '
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Contact: Phone#:
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Fax#:
Contractor License#:S'oo)7
Cupertino Business License#: Ct q rL95 a t5-
Job
J'ob Description:
Residential Commercial ❑
Valuation:
Project Size: Express Standard❑ Large 0 Major
Green Building: Please complete relevant portion of the Green Building Checklist&attach it to the
application or if applicable,include in plan set& the sheet index,
Green Building Points:
Quantity Fee ID Fee Description Fee .,Permit Type
Group
1PCSEWER. Commercial building P WPM
sewer/sanitaiy sewer
1BPREPIPE Commercial r,,-pipe per fixture P 1CPRP
1PGASCOM Commercial Oas Piping System P
1-4 Outlets
1BCBSC Cal Bldg Stan lards Commission B ALL P11RNHT
Fee WIPES
IBSEISMICOM Seismic Commercial P
Revised 01/07/09