B-2017-1160CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-1160
21221 GARDENA DR CUPERTINO, CA 95014-1619 (326 40 004) PURONICS SERVICE
INC
LIVERMORE, CA 94551
OWNER'S NAME: KASIRAJAN RAVICHANDRAN ET AL DATE ISSUED: 07/18/2017
OWNER'S PHONE: 408-981-1878 PHONE NO: (925) 456-7000
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Q6 Lic. #928595
Contractor PURONICS SERVICE INC Date 02/28/2019 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:
(N) WATER SOFTENER WHOLE HOURS UNIT
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
permit is issued.
APPLICANT CERTIFICATION
1 ertif that I have read this application and state that the above
information is correct. I agree to comply with all city and county ordinances
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
City of Cupertino against liabilities, judgments, costs, and expenses which
may accrue against said City in consequence of the granting of this permit.
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18
Signature Date 07-18-2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
z. I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project(Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three 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.
2. 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.
3. I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the
Worker's Compensation laws of California. If, after making this certificate of
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
be deemed revoked.
APPLICANT CERTIFICATION
1 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 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 City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non -point source regulations per the Cupertino Municipal
Code, Section 9.18.
Signature
Sq. Ft Floor Area: I Valuation: $2995.00
APN Number: Occupancy Type:
326 40 004
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Kim Dunbar
Date: 07/18/2017
RF ROOFS:
All roofs shall be inspected prior to any roofmg material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant:
Date: 07-18-2017
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:
Date: 07-18-2017
D NCY
I hereby affirm that there is a co r nding agency for the performance
of work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DF.CLA ATION
I understand my plans shall be used as public records.
Licensed
Date 07-18-2017 Professional
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 misc
CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • building(cDcupertino.org
PLUMBING MECHANICAL FIELECTRICAL MISCELLANEOUS
PROJECT ADDRESS 2 �+7 ( / _ r� ;� J /�
�r—�(��
-
APN # D - a0q
OWNER NAME �-A J I 11� �-�/f jA //
PHONE . � /7 ( . � ZS � 437
�S
E-MAIL
STREET ADDRESS
ZIZ-ZI 6.A27L n) A Dl2-
CITY, STATE, ZIP q FAX
G��G.i2—TWO G� 1561,1
CONTACT NAMEJEFF RAINEY
PHONE510-427-4260
E-MAIL
�effrey.rainey@att. net
STREET ADDRESS
1069 EDGEMERE LANE
CITY, STATE, ZIP
HAYWARD, CA 945454
FAX
510-783-1041
�q
❑ OWNER 11OWNER-BUILDER❑ OWNER AGENT ❑ CONTRACTOR 54 CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER 928595
LICENSE TYPE C36
BUS. LIC # 40137
COMPANYNAME Puronics
E-MAIL
FAX 925-456-7010
STREETADDRESS 5775 Las Positas Rd
CITY, STATE, ZIP Livermore, CA 928595
PHONE 925-456-7000
__7ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF FD or DUPLEX ❑ MULTI -FAMILY
BUILDING ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN ❑ YES
FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ YES
EICHLER HOME' ❑ NO
DESCRIPTION OF WORK I j ,A—►'t-iZ �T,J ,
TOTAL VALUATION. 2
RECEIVED 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 correct. 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 building construction. I a tatives of Cupertin ove-I entified property for inspection purposes.
Signature of Applicant/Agent: Date: '711 q11 7
UPPLEMENTAL INFO
N RE ED
OFFICE USE ONLY
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❑ OVER-THE-COUNTER
❑ EXPRESS
❑ STANDARD
❑ LARGE
❑ MAJOR
MEPMiscApp_2011.doc revised 06/21/11