B-2016-1895 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1895
22963 LONGDOWN RD CUPERTINO,CA 95014-2657(342 40 016) STREET PLUMBING
AND ROOTER
SAN JOSE,CA 95128
OWNER'S NAME: PANDE JYOTI P AND TANUJA DATE ISSUED:05/05/2016
OWNER'S PHONE:650-255-9377 PHONE NO:(408)496-1155
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class PLUMBING Lic.#582217
Contractor STREET PLUMBING AND ROOTER Date 12/31/2017 X BLDG —ELECT X 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 GAL WATER HEATER(GARAGE)
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.
2,1*4I 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:$950.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN
information is correct.I agree to comply with all city and county ordinances Number: Occupancy Type:
34240 016
and state laws relating to building construction,and hereby authorize 342
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 PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAS CTION.
I
Signatur Date 05/05/2016 Issued ELISSANA
Date:05/05/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I ant exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(See.7044,Business&Professions Code). Date:05/05/2016
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
t. 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. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&SafetyC ions 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:05/05/2016
1 certify that I have read this application and state that the above information is -CONSTRU4TION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 05/05/2016 Professional
GENERAL PERMIT APPLICATION M E Opm
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 M I C
(408)777-3228• FAX(408)777-3333• building(cDcupertino.org
CUPERT[NO r
PLUMBING
[:1 MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS 2Q V 5 L /)W 6 D®w � �.o A1,-) APN# -3 Y2,
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ONVNER NAME j/ /)-n p t 1�)E PHONF�/'r^,, rf' G3-7 7 E-KA L
STREET ADDRESS Z2q G 3 L0Nj G Pa-W)j f2D CITY, STATE,ZIP M(2e-rLfl'Q a CfSt I FAX
CONTACT A'AME . Sy-Ig� " PHO / qq&lI E-Nicol n&s4 er- p (A+.&i, e l
STREET.ADDRESS 21,9-3 `, I/; I��r ��V� tip CITY,STATE,ZIP �11.� /�( � l A. q�� F /r -qq6 -C 3�
❑ OWI.'ER ❑ OWNER-BUILDER ❑ OWNTER AGENT CONTR.0-TOR ❑CO\TRACTOR AGEt.T ❑ ARCHITECT (❑ENGA'EER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME AWpC LICENSE A'UA�ER �/J?^f I LICE'N'SE TYPE C 3 BUS.LIC O
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COMPANY NAME Wr�rPl P Aa n I,Si Oc. (��,�, - E MAjT�,,(.r te I __f_r\ �/ FAX � r / 3
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STREET ADDRESS y� r� p, r A , `pI ,j /n *n� CITY,STATE,ZIP t� � r,l�_ (��I PHO_' day /I��
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ARCHITECTlENGLNEER NAME LICENSE NUMBER I BUS.LIC r
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF FD orDUPLEX ❑ MULTI-FAMILY PROJECT RA IWILDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑ -\Es
BUJILDLNG: OmNiERCI.4L I URBAN INTERFACE AREA '�KNO FLOOD ZONTE NO EICHLER HOME? �NO
DESCRIPTION OF WORK �_• ,_ rQ ,/ - w o 1 6
TOTAL VALUATION: EIVEDB
By my signature below,I certify to each of the following: I am the property owner or authorized agent to o roperty owner's bIf ai
application and the information I have provided is correct. I have read the Description of Rork and verify it is accurate. I agree to c ply with pplicable local
ordinances and state laws relating to=I—
tion. I authorize representatives of Cupertino to enter the above 'd tifie -ope inspection purposes.
Signature ofApplicant/Anent: Date:
S PPLENIENTAL INTFOR-MATION REQUIRED
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AdEPA11iscApp_7011.doc revised 06/21/11