B-2017-1024CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1024
10455 BYRNE AVE CUPERTINO, CA 95014-2813 (357 12 066)
AFFORDABLE WATER
HEATERS AND
PLUMBING INC
28358
CONSTELLATION RD
VALENCIA, CA 91355
OWNER'S NAME: PATCHIPALA SESHARA,O AND PADMANATHI TRUSTEE
DATE ISSUED: 06/28/2017
OWNER'S PHONE: 661-993-6810
PHONE NO: (855) 345-9087
LICENSED CONTRACTOR'S DECLARATION_
BUILDING PERMIT INFO:
License Class C-M Lic. # 26 736@
Contractor AFFORDABLE WATER HEATERS AND PLUMBING INC Date
X BLDG _ELECT X PLUMB
—
09/30/2018
_ MECH X RESIDENTIAL — COMMERCIAL
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
JOB DESCRIPTION:
license is in full force and effect.
REPLACE 50 GAL WATER HEATER - SAME LOCATIO
I hereby affirm under penalty of perjury one of the following two declarations:
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
Section 3700 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area:
Valuation: $1300.00
permit is issued.
APPLICANT CERTIFICATION
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
357 12 066
and state laws relating to building construction, and hereby authorize
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We) agree to save indemnify and keep harmless the
PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino against liabilities, judgments, costs, and expenses which
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue against said City in consequence of the granting of this permit.
Additionally, the a pli rstands and will comply with all non-point
180 DAYS FROM LAST CALLED INSPECTION.
source regulatio . p he pertino Municipal Code, Section 9.18.
Issued by: Jasmine Archbold
Signature Date 6/28/2017
Date: 06/28/2017
R-B DE E LARAT
RE-ROOFS:
I hereby affir thatI am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two asons
installed without first obtaining an inspection, I agree to remove all new materials for
t. I, as er f the property, or my employees with wages as their sole
inspection.
compe ' ti n, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
Signature ofApplicant:
2. I, as owner of the property, am exclusively contracting with licensed
Date: 6/28/2017
contractors to construct the project (Sec.7044, Business & Professions Code).
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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
2. I have and will maintain Worker's Compensation Insurance, as provided for by
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
Section 3700 of the Labor Code, for the performance of the work for which this
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
s. I certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I us ent or devices which emit hazardous
air contaminants as defined by t e a Air Quality Management District I
shall not employ any person in any manner so as to become subject to the
will maintain compliance w' the ertino nicipal Code, Chapter 9.12 and
Worker's Compensation laws of California. If, after malting this certificate of
the Health & Saf ty Co Se 'ons 25 05, 25533, and 25534.
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
Owner or authorized ag nt:
be deemed revoked.
Date: 6/28/2017
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
CON RUC 0 E
I hereby affirm that there s a co tructi&Aending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this pe mit is sued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
Code, Section 9.18.
CUPERTINO
COMMUNITY DEVELOPMENT DEPARTMENT ^ BUILDING DIVISION
10300 TORRE AVENUE ° CUPERTINO, CA 95014-3255
(408) 777-3228 ^ FAX (408) 777-3333 • building aa.cupedno.org-
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COMPANY NAME
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STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF ❑ SFD or DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
1S THE BLDG AN ❑ YES
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK ® 14;64,12
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TOTAL VALUATION:��
IVED Y
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 e provided is correct. I have read the Description of Work and verify it is accuratet comply with all applicable local
ordinances and state laws relatin to u ding construction. I authorize representatives of Cupertino to enter the &ye-1-4�1,�.trficd mperty fOr ipspection purposes.
Signature ofApplicant/Agen . Date: 2 l7fC�/7/1 %L
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE USE ONLY
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