B-2016-1298 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1298
20277 NORTHBROOK SQ CUPERTINO,CA 95014-0503(316 39 062) (SOUTH COUNTY
PLUMBING)
SAN MARTIN,CA 95046
OWNER'S NAME: CHANDRAN KARTIK S AND SUNDARESH SUMAN TRUST DATE ISSUED:02/03/2016
OWNER'S PHONE:408-666-9986 PHONE NO:408-686-9411
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.# on q 9v _
Contractor(SOUTH COUNTY PLUMBING 1 Date�','3� �� XBLDG _ELECT X PLUMB
MECH X RESIDENTIAL COMMERCIAL 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. JOB DESCRIPTION:
REPLACE WATER HEATER SAME LOCATION
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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:$590.00
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 16 Number: Occupancy Type:
3
ordinances and state laws relating to building construction,and hereby 316 39 062
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 PERMIT EXPIRES IF WORK IS NOT STARTED
expenses which may accr a against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. ditionally,the applicant understands and will
comply with N,po - --in, rce-reg. ations per the Cupertino Municipal 180 DAYS FROM LAST CALLED INSPECTION.
Code,Sect' 1 ! ,%
Issued by:,1-9799
Signatu V � Date:
DER LARATION
_ RE-ROOFS:
I hereby affirm that If am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed.If a roof is
following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1. I,as owner of the property,or my employees with wages as their sole inspection.
compensation,will do the work,and the structure is not intended or offered
for sale(Sec.7044,Business&Professions Code) Signature of Applicant:
2. 1,as owner of the property,am exclusively contracting with licensed Date:
contractors to construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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 HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance,as provided for California Health&Safety Code,Sections 25505,25533,and 25534. I will
by Section 3700 of the Labor Code,for the performance of the work for which maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
this permit is issued. Health&Safety Code,Section 2553 a)should I store or handle hazardous
3. I certify that in the performance of the work for which this permit is issued,I material. Additionally,should I use a u�pment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the y ba,Air Quality Management District I
will maintain compliance with e u ' iggl Code,Chapter 9.12 and
Worker's Compensation laws of California. If,after making this certificate of the Health ety d ections 5 0 533,and 25534.
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 Owner oau h rize
be deemed revoked. Date: �� �
APPLICANT CERTIFICATION CON TR CTI N L NDINA
I certify that I have read this application and state that the above information is I hereby affirm that there i onst ctio lending agency for the performance
correct.I agree to comply with all city and county ordinances and state laws of work's for which this perms i Sec.3097,Civ C.)
relating to building construction,and hereby authorize representatives of this city Lender's Name
to enter upon the above mentioned property for inspection purposes. (We)agree
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant ARCHITECT'S DECLARATION
understands and will comply with all non-point source regulations per the I understand my plans shall be used as public records.
Cupertino Municipal Code,Section 9.18.
Licensed
Professional'
Signature Date
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
(408)777-3228• FAX(408)777-3333•building
cupertino.orct misc
13 --2616 -
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PROJECT ADDRESS&,2,72 Nolen, , L69 �^J,,_ APN# -31 / 2�1 (9 6 9
OWNER NAM n n ! L3 1 n/� P"P3� (�Q` IN Yo E-MAIL
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STREET ADDRESS rJ V U/Y CITY S)6ATTE_ZIP - FAX
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CONTACT NAME{ j l i� p, lv;p -s IP�l � `/,^� !) E-MAIL
STREET ADDRESS 0-� � �Typok
P-O-WNER ElOWNER-BUILDERElOWNER AGENT 1:1CONTRACTOR ❑CONTRACTOR AGY`ENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑ TENANT
CVjTRACTOR NAME � BUS.LIC#
C�rF MWfLG1�7BY F t1/�tL/ 1
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ARCHITECT/ENGINEER NAME IC SE NUMBER BUS.LIC#
COMPANY NAME N /} E-MAIL FAX
STREET ADDRESS / CITY,STATE,ZIP PHONE
USE OF ❑SFD.,DUPLEX ❑ MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK � J ,/j_� 7� y71� ` JV L�
TOTAL VALUATION: RECEIVED BY:
By my signature below,I certify to e ch o o iVIainproperty owner or authorized agent to act on the property owner's beh . Ihavereadthis
application and the information I h e p" vide a scription of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating o b� g Is cite represent es of Cupertino to enter the above en' ed property for inspection purposes.
Signature of Applicant/Agent: Date: C, 1611
777T
AL INF RMATION REQU oFF7cE USE ONLY
❑.OVER-THE-COUNTER'
c.
E' ❑ EXPRESS
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;, ❑ STANDARD
❑ LARGE
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❑"MAJOR
MEPMiscApp_2011.doc revised 06121/11