B-2016-3245 CITY OF CUPERTINO BUILDING PERMIT
,
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3245
10999 NQRTHSHORE SQ CUPERTINO,CA 95014-0535(316 38 022) STREET PLUMBING
AND ROOTER
SAN JOSE,CA 95128
OWNER'S NAME: POTTEK,KAT MADHAVADAS AND MATHILAKATH SINDHU DATE ISSUED:12/09/2016
OWNER'S PHONE:408-623-7196 1 PHONE NO:(408)496-1155
I
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO;
License Class C-36 Lic.#582217
Contractor STREET PLUMBING AND ROOTER Date 12/31/2017 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:
REPLACE(40)GAL WATER HEATER-GARAGE
I hereby affirm under penalty of perjury one of the following two declarations: I
1. I have and will maintain a certificate of consent to self:insure for Worker's i
46 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:$1200.00
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: i Occupancy Type:
and state laws relating to building construction,and hereby authorize 316 38 022 i'
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
mayd accrue againstsaidCity in stands and of the granting o this 'WITHIN 180 DAYS OF PERMIT,ISSUANCE OR
Additionally,the applicant understands and will comply with all non-pointi.
source regulations per the.. upertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
.----- 1
Signator ia•• Date 12/9/ 016 Issued by:Abby Ayende
Date: 12/09/2016
OWNER-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 roofmg 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:12/9/2016
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
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 Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 2 05,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent: 4 1
APPLICANT CERTIFICATION - Date:12/9/2016 r
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 whichthis 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, 1
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 12/9/2016
Professional
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=IT GENERAL PERMITAPPLCATIO
MEP
COMMUNITY DEVELOPMENT DEPARTMENT,BUILDING DIVISION
.,-e.fps 10300TORRE°AVENUE•CUPERTINO,CA 950114-3255 .
CUPERTINO- (408)777-3228•FAX(408)II1-3333-buiidinq(a�Cupertino.ord M
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STREET ADDRESS .2243 g T uT G R CITY,STATE, FAX -
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L OWNER 0 OWltERBUIL.DER 0 OWNER AGENT CONTRACTOR 000NmACTORAGEv'T 0 ARCHITECT_ 0 ENGLNETR El DEVELOPER 0 TENANT
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CONTRACTOR NAhRa Ti 'yAJ DtSENUABER , LICENSE TYPE / BUS.LIC T dJ
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COMPANY NAME
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STREET ADDRESS 3p r% y9 f^ /r
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ARCHITECT/ENGINEER NAME I LICENSE NtI BER Bus.
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PRONE
USE-of .. y SI-1)or Duplex p Multi-Family IPROTECT IN WH.DIAND PROJECT LN
r STRUCTURE: 0 Commercial - 1 URBAN mFTERFACE AREA 0 Yes 0 No FLOOD ZONE 0 Yes 0 No
DESCRIPTION:OFWORK pj�"p J." r �� k-fl B
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TOTAL VALUATION: I � ENEDBY .,` F ��' 4 .
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 provid is correct I haveread the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil.-.g . .. T authorize ,_-. K•:_.- of Cupertino to enter the abod :-iden Pied property for inspection proposes.
Signature of Applicant/Agent: Imo/ r "'� Date: f /�
SUPP ' t01TAL ThIIFORMATION REQUIRED F co c s E Ani
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MEPMiscApp_2011.dor revised 03/16/11