B-2016-2771 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2016-2771
10371 RIVERCREST CT CUPERTINO,CA 95014-1027(326 37 008) ALL VALLEY
PLUMBING INC
FREMONT,CA 94539
OWNER'S NAME: LOUISECHANDRAN JOEANAND AND LOUISCHANDRAN I DATE ISSUED:09/21/2016
OWNER'S PHONE:408-732-1391 PHONE NO:(510)661-9095
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERNUT INFO:
License Class D-afi Lic.#794890
Contractor ALL VALLEY PLUMBING INC Date 02/28/2017 X_BLDG —ELECT X PLUMB
I hereby affirm that I am licensedunder 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,SAME LOCATION
I hereby affirm under penalty of perjury one of the following two declarations:
i. 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.
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:$750.00
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 326 37,008
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 PERMITEXPIRES 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 app'cant understands and will comply with all non-point
source regulations a the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST-,CALi,F�SPECTION.
Signature - Date 09/21/2016 Issued by:
KIEL3 S�A'N'Alyi�``^ �
Date:09/26-2
OWNER-B iii DER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RF ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being inst�arar.
i. 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(Sce.7044,Business&Professions Code). Date:09/21/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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. 1 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 Cup rtino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cod ons 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorised agent:
APPLICANT CERTIFICATION Date:09/21/2016
I certify that I have read this application and state that the above information is CONSTRUCTION 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.
SiSignature Date 09/21/2016 Licensed
9 Professional
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT•-BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
Cti> PERTINO (408)777-3228•FAX(408)777-3333•buildingcDcupertino.org MISC
IvIBING 1,6 �a
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MECHANICAL ❑ELECTRICAL MISCELLANEOUS
PROJECT ADDRESS APN#
1 t year r + C+ - -
OWNERNAME �t ` C
Jo h V AS �o�® (2°Z" 1- 1 \ E-MAIL
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CONTACT NAME O E"�� v L,�E-MAIL -.
STREET ADDRESS �f® • \ CITY,STATE,ZIP FAX
❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT 'ILS CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
FCOMPANY
NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
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ME E-MAILFAX zL&Ax ESS CITY,STATE,ZIP PHONE
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ARCHITECT/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 ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES
BURRING: ❑COMMERCIALS URBAN INTERFACE AREA NO FLOOD ZONE ❑NO EICHLER HOME? ❑NO
DESCRIPTION OF WORK
570
TOTAL VALUATION: R�ECEIVEDBY:
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 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 building c uction. I author resentatives of Cupertino to enter the abovt-identified rope rry for inspection purposes.
Signature of Applicant/Agent: Date: \ 1`hd
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE USE ONLY
w ❑''OVER.THE-COUNTER..
❑.EXPRESS
{"ay ❑.STANDARD
a ❑°•.:LARGE
❑'.MAJOR
MEPMiscApp_2011.doe revised 06121111