09080159 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1 1010 NORTHSKY SQ CONTRACTOR:ALL VALLEY PLUMBING PERMIT NO:09080159
OWNER'S NAME: SITA SUBRANANIAN 3345 SELDON CT DATE ISSUED:08/18/2009
ER'S PHONE: 4084461574 FREMONT,CA 94539 PHONE NO:(510)376-4816
®� LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r— ELECT f— PLUMB
License Class L' # 6 7
- MECH r— RESIDENTIAL r COMMERCIAL r
Contractor toshvig
I hereby affirm that I am licensed under the Povisions of Chapter 9 JOB DESCRIPTION:WATER HEATER REPLACEMENT
(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 Sq,Ft Floor Area: Valuation:$350
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 A PN Number:31640065.00 Occupancy Type:
permit is issued.
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.1 agree tocomply 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.
indemnity 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 Issued Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. � ��
Sig Date��
RE-ROOFS:
111 roofs shall be inspected prior to any rooting material being installed. If a roof is
a OWNER-BUILDER DECLARATION nstalled without first obtaining an inspection,I agree to remove all new materials for
nspection.
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: signature of Applicant: Date:
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&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(See.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
1 hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the
declarations: California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain a Certificate of Consent to self-insure for Worker's --ompliance with the Cupertino Municipal Code,Chapter 9,12 and the Health&
Compensation,as provided for by Section 3700 of the Labor Code,for the iafety Code,Section 25532(a)should I store or handle hazardous material.
performance of the work for which this permit is issued. kdditionally,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for b 'ontaminants as defined by the Bay Area Air Quality Management District I will
p p y naintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Section 3700 of the Labor Code,for the performance of the work for which this iealth&Safety Code,Sections 25505,25533,and 25534.
permit is issued.
I certify that in the performance of the work for which this permit is issued,1 shall ner a horized a n : —sL� D �,„ ��
not employ any person in any manner so as to become subject to the Worker's !2 ate: j�
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I mustf CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked. hereby affirm that there is a construction lending agency for the performance of work's
br which this permit is issued(Sec.3097,Civ C.)
APPLICANT CERTIFICATION .ender's Name
1 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 endcr's Address
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
it lily and keep harmless the City of Cupertino against liabilities,judgments,
c,1 and expenses which may accrue against said City in consequence of the 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 re ations per the Cupertino Municipal Code, ection icensed Professional
9.18
Signa ate
04 0 Wq
.� CITY OF CUPERTINO
} - WATER ]SEATER
`SCUP Of
PERMIT APPLICATION FORM
APN # Date-.
y
Building AddrNes
Owner's Name: Phone #:
Lf
Phone #:fi c--(,3&)t--rj Cly
Contractor:
..., Fax #: 510-- (0(01 — Lq 7
Cupertino Business License#:
Contractor State License #:
.� SCIS �,-- (Qui- ��c<�
5!
Contact: Phone#:
Fax #: �IC, _ � _ C* 7�,
Building Perrrut Info:
Bld ❑
P-..umb [�'� Mech F i
Elect
Residential (� Commercial F-1
Job Description:
Re lacement ❑
Strapped On Platform Bonded ' New Location P
Valuation (cost of project):
Project Size: Express Standard❑ Large ❑ Major[]
J
Building:: Please complete relevant portion of the Green Building Checklist
ist & attach it to
,,reen g
the application or if applicable, include in plan set & the sheet
Green Buildin Points achieved:
Revised 6/16/08