B-2016-3170 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS. -2016-3170
21813 TERRACE DR CUPERTINO,CA 95014-4776(356 17 018) CONTRACTOR:
PERMIT NO:B
SERVICE
CUPERTINO,CA 95014 •
OWNER'S NAME: GOVENDER KANDHARUBEN AND SAROJENI DATE ISSUED:j 11/28/2016
OWNER'S PHONE:408-425-3836 PHONE NO:(408)1375-3140
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class SANITATION SYSTEM Lic.#958020
Contractor MARTI'S PLUMBING SERVICE Date 02/28/2017 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:
I hereby affirm under penalty of perjury one of the following two declarations: REPLACE TWO WAY CLEAN-OUT-
BUILDING
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.
I have and will maintain Worker's Compensation Insurance,as provided for by
-Jae Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$23501.00
APPLICANT CERTIFICATION
I 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 35617 018
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 Date 11/28/2016 Issued by:Kim Dunbar
Date: 11/28/2016
OWNER-BUILDER 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 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(Sec.7044,Business&Professions Code). Date:11/28/2016
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. 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
Health&Safety Code
s. I certify that in the performance of the work for which this permit is issued,I should I store or handle hazardous
Section 25532(a)
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 Mu,icipal Code,Chapter 9.12 and
exemption,I become to the Compensationprovisions of theSafety � ns 25515,25533,and 25534.
P subjectp the Health&Safe Cod• echo
Labor Code,I must forthwith comply with such provisions or this permit shall 1
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION Date:11/28/2016
I certify that I have read this application and state that the above information is LADING AGENCY
CONSTRUCTION LE
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. I understand my plans shall be used as public records.
Licensed
Signature Date 11/28/2016 Professional
GENERAL PERMIT APPLICATION _MEP
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
sn, 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228• FAX(408)777-3333•building(,cupertino.orqMISC
CUPERTINO
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OWNER ❑ OWNER-BUILDER 0 OWNER AGENT 0 CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER ❑ DEVELOPER 0 TENANT
CONTRAC. 1E 1 ` , LICEe yy�'NyII E /f/6) LICENSE TYPE BUS. /
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COMPANY Np4A_ f/ pfveo„ E-MAIL FAX
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ARCHITECT/ENGINEER NAME LICENSE NUMBER • BUS.LIC 4
COMPANY NAME E-MAIL , FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF 0 SFD or DUPLEX 0 MULTI-FAMILY PROJECT IN WILDLAND 0 YES . PROJECT IN 0 YES IS THE BLDG AN 0 YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA NO FLOOD ZONE . 0 NO '.''. EICHLER HOME? 0 NO
DESCRIPTION OF WORK ti
.. --7444INS ` 1_
'O W1r-- adv l ,
TOTAL VALUATION:r-' 2 3,542---
By
"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 co x ct. 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• • g construe'ion. I authorize representatives of Cupertino to enter the above-identtiff d/property for inspection purposes.VIP
Signature of Applicant/Agent: Date: 11/2..8
j
777
SUPPLEMENT=I INFORMATION REQUIRED
7 I❑,OViiiffittL'COLINTErtij-
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MEPMiscApp_2011.doc revised 06/21/11