B-2016-2427CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2427
10382 MENHART LN CUPERTINO, CA 95014-3631 (375 16 010) PAB CONSTRUCTION
INC
CUPERTINO, CA 95014
OWNER'S NAME: MUSUGU MANJUSHA AND YANAMALARAMA DATE ISSUED: 08/01/2016
OWNER'S PHONE: 408-499-6599 PHONE NO: (408) 499-6595
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic. #980537
Contractor PAB CONSTRUCTION INC Date 01/31/2017
hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
ith Section 7000) of Division 3 of the Business & Professions Code and that my
cense is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
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 ofthe work for which this permit is issued.
z 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.
APPLICANT CERTIFICATION
I certify that 1 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 ber + Crupertino Municipal Code, Section 9.18.
Date18! /2016
hereby affirm that I am exempt from the Contractor's License Law for one of the
two reasons:
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 (Sce.7044, Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (See.7044, Business & Professions Code)..
I hereby affirm under penalty of perjury one of the following 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
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 1 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.
Signature Date 8/1/2016
BLDG X ELECT —PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
JOB DESCRIPTION:
(N) TEMPORARY POWER POLE (100 AMP); POLE
Sq. Ft Floor Area: Valuation: $600.00
APN Number: Occupancy Type:
375160
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Abby Ayende
Date: 08/01/2016
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:
Date: 8/l/2016
ROOF COVERINGS TO BE CLASS "A"
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 Cuper 'no Municipal Code, Chapter 9.12 and
the Health &Safety Code, ecti J;7,25533, and 25534.
owner or authorized agent:
Date: 8/1/2016
N TRVIDINGAGENCY
I hereby affirm that there is a co uction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional
CUP RTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(a1cupertino.org
❑ PLUMBING ❑ MECHANICAL ELECTRICAL ❑ MISCELLANEOUS
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CONTACT NAME J' Y PHONE E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
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❑ OWNER ❑ OWNER -BUILDER/-} 1:1OWNERAGENT El CONTRACTOR El CONTRACTOR AGENT ❑ ARCHITECT ElENGINEER 11 DEVELOPER 11 TENANT
CONTRACTOR NAME h n / LICENSE NUMBER C LICENSE TYPE BUS. LIC #
COMPANY NAME V` t' q E-MAIL
STREET ADDRESS CITY, STATE, ZIPv _/a� rl e PHONE
ARCFnTECT/ENGINEER NAME LICENSE NUMBER BUS. LIC #
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY, STATE, ZIP PHONE
USE OF ❑ SFD Or Duplex ❑ Multi -Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ No
DESCRIPTION OF WORK. b (jo a P)
TOTAL VALUATION:
By my signature below, I certify to each of the llo g: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the infonnation I have provide co ec 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 building c tru 'o . I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature ofApplicant/Agent: Date: (� 8
AL INFORMATION
MEPMiscApp_2011.doc revised 03116111
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