B-2016-2639 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: - CONTRACTOR: PERMIT NO:B-2016-2639
20335 VIA VOLANTE CUPERTINO,CA 95014-6316(316 01 036) STREET PLUMBING
AND ROOTER
SAN JOSE,CA 95128
OWNER'SNAME: CHAKRAVARTHYRAMUAND GAYATHRl DATE ISSUED:09/01/2016
OWNER'S PHONE:408-921-0259 PHONE NO:(408)496-1155
I N D TRACTOR'FRACTOR'S DECLARAIJON BUILDING PERMIT INFO:
License Class Q-_M Lic.#582217
Contractor STREET PLUMBING AND ROOTER Date 1213172017 X BLDG —ELECT _PLUMB
MECH X RESIDENTIAL_COMMERCIAL
I 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 50 GALLON WATER HEATER-GARAGE
I hereby affirm under penalty of perjury one of the following two declarations:
i, 1 have and will maintain a certificate of consent to self-insure for Worker's
f 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:$1000.00
APPLICANT CERTIFICATION
certify that I have read this application and state that the above
information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 316 01036
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 upertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature i' Date 9/1/2016 Issued by:Abby Aygnde
,. Date:09/01/2016
O TiER-BUILDER DECLARATION
I hereby affirm that I am 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. 1,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(Sec.7044,Business&Professions Code). Date:9/1/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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, 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
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
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
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 Cu "tino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code, e,tions 2550 , 5533,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:9/1/2016
I certify that 1 have read this application and state that the above information is CONST LENDINGUCUON ENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a co struction 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 ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
Signature Date 91112016 Professional.
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•building(akupertino.org
CUPERTINOMISC
,PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESSV 9 A I O I A► 1 APN#
OWNER NAME s de y /�i f y w V^12A,,jA p L PHO /�/ .. E IU C� ICA Y�
STREET ADDRESS-��r 1 �/ 1 V i AF � ! CITY, STATE",ZIP R, 1 52 t 4 FAX
CONTACT NAME �^ PHONE i/y�� Z06-/, mb j �G-) ,r/®
STREET ADDRESS 12—I 3 V VIuLC( Cc�a QVC TY, (LO�® (�� (T
❑OWNER ❑. OWNER-BUILDER ❑ OWNER AGENT XIINTRACTOR ❑CONTRACTORAGENTl ❑-ARCHITECT ❑ENGINEER ❑. DEVELOPER ❑TENANT
CONTRACTOR NAME ,dV c'-' LICENSE NUMBER s9,4 1 LICENSE TYPE ?/ BUS.LIC# •:')
COMPANY NAME E !i-I �I FAX
STREET ADDRESS ,,� , `Lr iy g ,� CITY,STATE,ZIP PQ-
ARCHITECT/ENGINEERNAME ll[.I�+ v J LIC SE NUMBER BUS.LIC f J
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE.OF ° or Duplex ❑ Multi-Faintly PROJECT IN WILDLAND PROJECT IN
STRUCTURE: ❑ Commercial URBAN INTERFACE AREA ❑ Yes ❑ No FLOOD ZONE ❑ Yes ❑ NO
DESCRIPTION OF WORK /1
-110-A
'10-A
TOTAL VALUATION: RECEIVEDBY
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is cone�th
�` q
Des tion of Work and verify itis accurate. I agree to comply with all applicable local
ordinances and state laws relating t ves of Cupertino to enter the above-identif7id property for inspection purposes.
Signature of Applicant/Agent: Date: t
PP NT RMATION REQUIRED OFFICE,CISE ONLY ...
W D,.OVER-THE COUNTE77777, R
, �, � STANDaRU
k�
❑ LARGE
MAJOR,,.
MEPMiscApp_2011.doc revised 03116/11