B-2016-1768 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1768
22314 CUPERTINO RD CUPERTINO,CA 95014-1044(326 50 085) AFFORDABLE WATER
HEATERS AND
PLUMBING INC
VALENCIA,CA 91355
OWNER'S NAME: SANJAY AND GEETHA TRUSTEE RAO DATE ISSUED:04/15/2016
OWNER'S PHONE:408 813 5626 PHONE NO:(855)345-9087
LICENSED CONTRACTOR'S DECLARAIION BUILDING PERMIT INFO:
I
License Class PLUMBING Lie.#52730
Contractor AFFORDABLE WATER HEATERS AND PLUMBING INC Date X BLDG —ELECT —PLUMB
09/30/2016 MECH X RESIDENTIAL_COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter(commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my JOB DESCRIPTION:
I
icense is in full force and effect. REPLACE 75 GALLON WATER HEATER SAME LOCATION
I hereby affirm under penalty of perjury one of the following two declarations: (BASEMENT)
1. 1 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. 1 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 Sq Ft Floor Area: Valuation:$6320.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN Number: Occupancy Type:
information is correct.I agree to comply with all city and county ordinances 326 50 085
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 PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino against liabilities,judgments,costs,and expenses which WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue against said City in consequence of the granting of this permit.
Additionally,the applicant understands and will comply with all non-point 180 DAYS FROM LAST CALLED INSPECTION.
source regulations per the Cupertino Municipal Code,Section 9.18.
Issued by:Patricia Garcia
Signature Date Date:04/1.5/2016
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
i. 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(See.7044,Business&Professions Code) Signature of Applicant:
2. I,as owner of the property,am exclusively contracting with licensed Date:
contractors to construct the project(See.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following
ROOF COVERINGS TO BE CLASS"A"OR BETTER
1.
three 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 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 by California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Section 25532(x)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 9.42 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
consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my pians shall be used as public records.
Code,Section 9.18.
Licensed
Professional
Signature Date
0411412016 14:00 krAA; ••�-
GENERAL PERMIT APPLICATION mmm E P
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
GUi'ERTFNC! 1
(408)777-3228 FAX(408)777-3333•buildincl(Q-cupertino:org mist;
All
W'LUMBING ME-CIIANICAL ❑F.•LFCTRICAL ❑MISCELLANEOUS
1'RO1L'C7I'AClDRESS ✓
OWNER NAMEQ ^ate PI10 F. OT b^ �N j L'-MAIL
STRF.ETADDRESS CITY,STArE,ZIP, t FAX I
a 2r h
E TAIL
CONTACT NAME �` ` E O P S OL
S 1 RrET ADDRESS n (TY,STATE,ZIP U
2& s Go l Cl, erl C C1 Of
_ 13 SS tel-
• ❑OWNER 11 OWNER-BUILDER 11OWNERAGENT ❑ CONTRACTOR L¢C'ON'TRACTOR AGENT ❑ ARCHITC•cl' ❑ENGINEER ❑ DEYEI.OPER. El TENANT
CONTRACTORN E LICENSE NUMBER LICENSETYPE C1 to HUS.111C it 2-IJ R's
Affordable Water He
COMPANY NAME 28358 Constellation Road Ste 69. E-MAIL FAX
STREET ADDRESS a encia,CA 91355 CITY,STATE,ZIP PHONE.
ARCIIITECTIENGWL'r•R NAME LICENSC NUMBER HUS-LIC 0
COMPANY NAME E-MATE FAX -
FBUILD1.NG:
ADDRESS CITY,STATE,71P PHONE -
OF .,DUPLEX ❑ MUCrT-FAMILY PROJECT W WILDLAND ❑ YES PROJECr IN ❑YES IS THE DLDG AN ❑YES
❑COMMERCIAL URBAN INTERFACE AREA ❑ NO
FLOOD ZONE ❑NO EICHl.ER HOME? ❑.NO
DESCRIPTION OF WORK n '0, /�� a e t-e �/ __ .t a--".e r--
-(� k�
TOTAL VALUATION: u Z OBy my signature below,1 certify to each of the following: 1 am the
,property owner or authorized agent to act on the property owner's behalf. I have read this
application and the inibraiation 1 have provided is correct. I have read the Description of Work and verify It is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buildinno ction. 1 authorize representatives of Cupertino to enter the above-identified roperty for inspection purposes.
Signature of Applicant/Agent: Date:
!3
- s `oei useTe'i~
SUPPLI>MN'1'ALINFORMA ON REQUIRED
- -_�•.'-:k�.':'(2_�?EIt- EESCBUi�,'F1Et;{;r�',_';"
' -SeiE:?dic'' -=- `�•SS ''ii?-+"V�_�E•`�?Cci^.
--
4-r
_'•' � __ --_ -- _ _--_ --_--- pit
J111.TPX1iscApp_201 Ldoc revised 06121111