B-2016-1190 Permit CardCITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS; CONTRACTOR: PERMIT NO: B-2016-1190
10737 PAR THREE DR CUPERTINO, CA 95014-4025 (356 07 041) ( S f K GROUP INC)
SANTA CLARA, CA
95050
OWNER'S NAME: VINODKUMAR MAMPATTA V AND ERINGATHODI GEETH
OWNER'S PHONE:
LICENSED CONTRACTOR'S DECLARATION
License Class Lie. # oo
Contractor ( S J K GROUP INC ) Date
I hereby affirm that I am licensed under the provisions of Chapter 9 (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:
r. 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.
2. 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 whi
this permit is issued.
APPLICANT CERTIFICATION
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 enter 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
granting of this permit. Additionally, the applicant understands and will
comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
Date i/1gJJG
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following five reasons:
a. I, 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)
2. 1, as owner of the property am exclusively contracting with licensed
contractors to construct the project (Sce.7044, Business & Professions Code),
I hereby affirm under penalty of perjury one of the following three declarations:
r. I have and will maintain a Certificate of Consent to self-mame 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.
2. 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.
3. I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the
Worker's 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 must forthwith comply with such provisions or this permit shall
be deemed revoked.
APPLICANT CERTIFICATION
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 enter 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 granting of this permit. Additionally, the applicant
understands and will comply with all non -point source regulations per the
Cupertino Municipal Code, Section 9.18.
ISSUED: 01/14/2016
BUILDING PERMIT INFO:
X BLDG —ELECT —PLUMB
_ MECH X RESIDENTIAL _ COMMERCIAL
SOB DESCRIPTION:
Kitchen Remodel (130 S.f); Remove (E) slider door at kitchen and enclose;
Remove 2 non load bearing walls (80 S.£)
Ft Floor Area: I Valuation: $18000.00
Type;
07 041
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
RE -ROOFS:
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.
Signature of Applicant:
ALL ROOF
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:
Date:
CONSTRUCTIO LE 'E CY
I hereby affirm that there Is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
ARCHITECT'S DECLARATION
understand my plans shall be used as public records.
Date