B-2016-3003CITY OF CUPERTINO BUILDING PERMIT
BUIL INGADDRESS:
1220 "YMOTH DR CUPERTINO, CA 95014-4958 (362 10 037)
NAME: SIVASANKAR MOHAN N AND MOHAN GEETHA TRUSTEE
'S PHONE: 408-569-7875
Class C-36 Lic. #582217
:or STREET PLUMBING AND ROOTER Date 12/31/2017
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.
affirm under penalty of perjury one of the following two declarations:
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.
APPLICANT CERTIFICATION
I certi y that I have read this application and state that the above
information is correct. I agree to comply with all city and county ordinances
and s ate laws relating to building construction, and hereby authorize
repre entatives 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.
and
Date 10/27/2016
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 (Sec.7044, Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec.7044, Business & Professions Code).
y affirm under penalty of perjury one of the following three declarations:
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.
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
/ that I have read this application and state that the above information is
I agree to comply with all city and county ordinances and state laws
3 to building construction, and hereby authorize representatives of this city
:r upon the above mentioned property for inspection purposes. (We) agree
indemnify and keep harmless the City of Cupertino against liabilities,
-nts, costs, and expenses which may accrue against said City in
Iuence of the granting of this permit. Additionally, the applicant understands
II comply with all non -point source regulations per the Cupertino Municipal
Section 9.18.
Date 10/27/2016
CONTRACTOR; PERMIT NO: B-2016-3003
STREET PLUMBING
AND ROOTER
SAN JOSE, CA 95128
DATE ISSUED: 10/27/2016
PHONE NO: (408) 496-1155
BUILDING PERMIT INFO:
BLDG —ELECT X PLUMB
MECH X RESIDENTIAL _ COMMERCIAL
DESCRIPTION:
.,ACE 50 GALLON WATER HEATER (SAME LOCATION)
Ft Floor Area: Waluation: $1800.00
APN Number: Occupancy Type;
362 10 037
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
by: Abby Ayende
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: 10/27/2016
TO BE CLASS "A" OR
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 Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505 25533, and 25534.
Owner or authorized agent:
Date: 10/27/2016 COA�iTRU�CTIQN�L�� AGENCY
I hereby affirm that there is a construction lending agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITEC'T'S. DECLARATION
understand my plans shall be used as public records.
Licensed
Professional
r
GENERAL PERMIT APPLICATIONa16_3CG MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(aDcupertino.orp
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USE OF SFD Or Duplex ❑ Multi -Family PROJECT IN WILDLAND PROJECT IN
STRIICTURE: ❑ C011ll�ri-eprClal URBAN INTERFA)))CE AREA El Yes ❑ NO FLOOD. ZONE ❑ Yes El No
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VALUATION: Is 60
By fey signaturehelow, 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
app] ication and the information I have provided is correct. I ha ad the Description of Work and verify it is accurate. I agree to comply with all applicable local
�oxdipances and state laws r Latin uil ' i autho ' ntatives of Cupertino to enterthe above -i entified p operry for inspection purposes.
Sigell ature of Applicant/Agent: Date: (�
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l UPP ORMATION REQUIRED
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MEPMiscApp 2011.doc revised 03/16/11