B-2016-3098CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: '
10790 MINETTE DR CUPERTINO, CA 95014-3615 (375 31 034)
CONTRACTOR:
PERMIT NO: B-2016-3098
OWNER/BUILDER
OWNER'S NAME: KELKAR UMESHAND PREETI U
DATE ISSUED: 04/06/2017
OWNER'S PHONE: 408-891-5752
PHONE NO:
BUILDING PERMIT INFO:
LICENSED EN D CONT ACTOR'S DECLARATION
License Class Lic. #
Contractor OWNE /B IDR Date
X BLDG —ELECT _ PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
— MECH X RESIDENTIAL — COAIMERCIA.L
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:
CONSTRUCT ONE STORY HOME (2617 S.R); ATTACHED GARAGE
1. I have and will maintain a certificate of consent to self -insure for Worker's
(414 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.
2. 1 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: 3031
Valuation: $400000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
375 31 034
R-3 (Custom),R-3 (Custom),U (Private Gar /Ag Bldg),U
representatives of this city to enter upon the above mentioned property for
(Private Gar /Ag Bldg)
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.
PERMIT EXPIRES IF WORK IS NOT STARTED
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18..
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 04/06/2017
Issued by: Kim Dunbar
OWNER -BUILDER DECLARATION
Date: 04/06/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
RE.ROOFS
s. 1, as owner of the property, or my employees with wages as their sole
All roofs shall be inspected prior to any roofing material being installed. If a roof is
compensation, will do the work, and the structure is not intended or offered for
installed without first obtaining an inspection, I agree to remove all new materials for
sale (Sec.7044, Business & Professions Code)
inspection.
z. J I, as owner of the property, am exclusively contracting with licensed
'
contractors to construct the project (Sec.7044, Business & Professions Code).
Signature ofApplicant:
I hereby affirm under penalty of perjury one of the following three declarations:
Date: 04/06/2017
1. I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 bf the Labor Code, for the
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
HAZARDOUS MATERIALS DISCLOSURE
Section 3700 of the Labor Code, for the performance of the work for which this
I have read the hazardous materials requirements under Chapter 6.95 of the
permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
3. I certify that in the performance of the work for which this permit is issued, I
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
shall not employ an
p y y person in any manner so as to become subject to the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
Worker)'� Compensation laws of California. If, after making this certificate of
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
exemption, I become subject to the Worker's Compensation provisions of the
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Labor Code, I must forthwith comply with such provisions or this permit shall,
the Health & Safety Code, Sections 25505, 25533, and 25534.
be deemed revoked.
APPLICANT CERTIFICATION
n/
Owner or authorized agent://
certify that I have read this application and state that the above information is
Date: 04/06/2017
correct. I agree to comply with all city and county ordinances and state laws
CONSTRUCTION LENDING AGENCY
relating to building construction, and hereby authorize representatives of this city
I hereby affirm that there is a construction lending agency for the performance
to enter upon the above mentioned property for inspection purposes. (We) agree
of work's for which this permit is issued (Sec. 3097, Civ C.)
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Name
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
Lender's Address
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature �f ► 6 i t�\� Date 04/06/2017
Licensed
Professional