B-2016-0968CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0968
11103 WILKINSON AVE CUPERTINO, CA 950144734 (356 17 038)
SUCCESS WATER
SYSTEMS INC
BRENTWOOD, CA
94513
OWNER'S NAME: GOPALAKRISHNAN KARTHIK AND KRISHNAN UMA
DATE ISSUED: 06/20/2017
OWNER'S PHONE: 408-455-5008
PHONE NO: (800) 287-8798
LICENCED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C-36 Lic. #701671
Contractor SUCCESS WATER SYSTEMS INC Date 11/30/2017
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 for and effect.
JOB DESCRIPTION:
INSTALL (N) WATER FILTRATION/SOFTNER
I hereby affirm der penalty of perjury one of the following two declarations:
t. I ha a and will maintain a certificate of consent to self-insure for Worker's
C mpensation, as provided for by Section 3700 of the Labor Code, for the
erformance 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: $2500.00
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
356 17 038
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 th1qgranting of this permit.
Additionally, the applicant understands and will mply with all non-point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Muni ' al Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 6/20/2017
Issued by: Abby A e} nde
Date: 06/20/2017
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 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: 6/20/2017
1 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 hazardou
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 hawaous
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined by the Bay Area Air Quality Manageme istrict I
will maintain compliance with the Cupertino Municipal Code, C>4ter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Seed 05, 25533, a 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized ages
APPLICANT CERTIFICATION
Date: 6/20/2017
1 certify that I have read this application and state that the above information is
DING 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.
Signature Date 6/20/2017
Licensed
Professional
CUPERTINO
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building�i-)cuaertino.org
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USE OF S DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
❑ YES
❑ NO
IS THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK��
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TOTAL VALUATION:
RECEIVED BY:
By my signature below, I certify to each of the following: I am the property ner or authorized agent to act on the property owner behal . I have read this
application and the information I have provided is correct. I have read t escription of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to build co tion. I autho ' e representatives of Cupertino to enter the above -id tifie roperty or inspection purposes.
Signature of Applicant/Agent: Date:
S LEMENTAL INFORMATION REQUIRED
OFFICE USE ONLY
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MEPMiscApp_2011.doc revised 06121111