B-2017-0189 Def #1 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0189
21030 GARDENA DR CUPERTINO,CA 95014-1616(326 08 044) PROVISION
DEVELOPMENTINC
SUNNYVALE,CA
94085
OWNER'S NAME:SIVAPRAKASAM SURESH DATE ISSUED:05/24/2017
OWNER'S PHONE: PHONE NO:(408)245-0991
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class j3 Lip.#858391
Contractor PROVISION DEVELOPMENT INC Date 05/31/2019 X BLDG_ELECT_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:
CONSTRUCT ONE STORY HOME(3613 S.F.);ATTACHED GARAGE
I hereby affirm under penalty of perjury one of the following two declarations: (462 ST.);COVERED PATIO(164 S.F.);FRONT PORCH(72 S.F.).
t. I have and will maintain a certificate of consent to self-insure for Worker's DEF#1-TRUSS CALCS-ISSUED 7/11/18
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
z. 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:4075 Valuation:$650000.00
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 326 09 044 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 t
City of Cupertino against liabilities,judgments,costs,and ex nse h
may accrue against said city Inconsequence oft grant g o hl permit. PERMIT EXPIRES IF WORK IS NOT STARTED
Additionally,the applicant understands��nnd-wrl comp) It�on-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cu ctlntSMunicip e,Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signatur - Date 07/1112018
Issued by:Kim Dunbar
/OWNER-BUILDER DECLARATION Date;05/24/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons: RE-ROOFS;
i. I,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 fust obtaining an inspection,I agree to remove all new materials for
sale(Sec,7044,Business&Professions Code) inspection,
2. I,as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec,7044,Business&Professions Code). Signature ofApplicanh
Date;07/11/2018
I hereby affirm under penalty of perjury one of the following three declarations:
t. I have and will maintain a Certificate of Consent to self-insure far Worker's ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 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 Cade,Sections 25505,25533,and 25534.I will
s. 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 any person in any manner so as to become subject to die Health&Safety Code,Section 25532(a)should I store or handle hazardous
material.Additionally,should I use equipment or devices which emit hazardous
Worker's Compensation laws of California.If,after making this certificate of air contaminants as defined by the Bay Area Air Quality Management D ti
exemption,I become subject to the Worker's Compensation provisions of the will
maintain compliance with the Cupertino Municipal Coil¢,-E ter -2 and
Labor Code,I must forthwith comply with such provisions or this permit shall the Health&Safety Code,Sectlona 255 25 3,and
be deemed revoked.
APPLICANT CERTIFICATION Owner or authorized
I certify that I have read this application and state that the above information is Date;07/11/2018_—
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 heyeb affirm that there Is a construction lending agency for the performance
to enter upon the above mentioned property for Inspection purposes. (We)agre work's for which this permit Is Issued(Sec.3097,Civ C.)
to save indemnify and keep harmless the City of Cupertino against Ilabllitl s;' Lender's Name
judgments,costs,and expenses which may accrue against said City In-
consequence of the granting of this permit.Additionally,the applrant understands Lender's Address
and will comply with all non-point source regulatlons per th€'Cupertlno Municipal
Code,Section 9.18. -^' ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date 0 7111/2 01 8 Licensed