B-2016-1448 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1448
10239 PALO VISTA RD CUPERTINO,CA 95014-2712(357 01 072) (AFFORDABLE WATER
HEATERS AND
PLUMBING INC)
VALENCIA,CA 91355
OWNER'S NAME: TAMBE ATULAAND ROHINI TRUSTEE DATE ISSUED:02/29/2016
OWNER'S PHONE:408-316-4436 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lie.#627368
Contractor(AFFORDABLE WATER HEATERS AND PLUMBING INC)Date X BLDG —ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE 50 GALLON WATER HEATER IN THE 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.
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. Sq.Ft Floor Area: Valuation:$2289.00
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 APN Number: Occupancy Type:
ordinances and state laws relating to building construction,and hereby 357 01 072
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 accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will
comply with ail non-point source regulations per the Cupertino Municipal 180 DAYS FROM LAST CALLED INSPECTION.
Code,Section 9.18.
Issued by:Susan Winslow
Signature Date Date:
OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I 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. I,as owner of the property,am exclusively contracting with licensed Date:
contactors 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. 1 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 25532(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 equipment 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 Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
Worker's Compensation laws of California. If,after making this certificate of the Health&Safety Code,Sections 25505,25533,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 or authorized agent:
be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction 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 permit is issued(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 ARCHITECT'S DECLARATION
consequence of the granting of this permit. Additionally,the applicant
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
UZIZSIZUIb 13:U (I-AA) r.uu l luu l
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228-FAX(408)777-3333•buildinDCa)-cupertino.org
El NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DFFERRED ORIGINAL PERRMp I'1'#
PROJECTADDRESS ll^�I t , c _ •. 7APN
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OWNERNAME D U PHON4UZ E-MAIL�` /
STREET ADDRESS o Z CT '0.. CITY, STAT'Zit' �O FAX
CONTACT NAME - PHONE E•-M 1L
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STREET ADDRESS I + I�F o n- UR4 CIT , TATT Zl P � 1 FAX
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❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ❑ CONTRACTOR bCONIRACTORAGENI ❑ ARcHrrrcr ❑ENGINEER ❑ DEVELOPER ❑.TENANT
CONTRACTOR AME AffordableLICENSE NUMBER Z�?j LICENSE TYPE ^ HUS.LtC @
COMPANY NAME 28358 Constellation Road Ste 6 BCMAIL FAX
STREET ADDRESS Valencia,CA 91355 CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LICE •
COMPANY NAME E-MATT. FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK a Ce W -e ate l".
loca ± lo
EXISTINGUSE - PROPOSED USE CONSTR.TYPE #ST IES
USE TYPE OCC. SQ.FT. VALUATION(S)
EXISTG NEW FLOOR DEMO TOTAL --
AREA AREA AREA NET AREA
BATHROOM KITCHEN OTHER
REMODEL AREA REMODEL AREA REMODEL AREA
PORCH AREA. DECK AREA. TOTAL DECKIPORCH AREA GARAGE AREA: DETACH
❑ATTACH
kDWELLING UNITS: ISA SECOND UNIT OYES SECONDSTORY OYES
BETNGADDED? ONO ADDITION? ONO
PRE-APPLICATION OYES IF YES,PROVIDE COPY OF 1S THE BLDG AN ❑YES _- --__- T TAL VALUATION:
PLANNINGAPPL# ONO PLANNING APPROVAL LETTER EICHLERHONJE? 0 N e :y
-
By my signature below,t certify to each of the following: I am the property owner or authorized agent to act on the property owner's behal•. I have read this
application and the information I have provided is correct_ T have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and stale laws relating to build* construction. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: 2
SUPPLEMENTAL INFORMATION REQUIRED
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existing building(s). Demolition permit Is required prior to Is.uance of building __._________...._._.,.._.....__..._ _........_,._-_..,.._.._.._
emit for new building.
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Commercial Bid s: Provide a completed Hazardous Materials DISCIOSUYC
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rm ifany Hazardous Materials are being used as part of this project.
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