B-2017-0002CITY OF CUPERTINO
BUILDING PERMIT
BUILDING ADDRESS:91
CONTRACTOR:
PERMIT NO: B-2017-53*10
804 BETLIN AVE CUPERTINO, CA 95014-4547 (369 27 039)
CUPERTINO
PLUMBING INC
SAN JOSE, CA 95124
OWNER'S NAME: VENUGOPAL MADAN AND MADAN SITYAMA TRUSTEE
DATE ISSUED: 01/03/2017
OWNER'S PHONE: LAOS,--QQ yy'�
t 2Z`'[
PHONE NO: (408)253-0618
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class PLUMBING Lic. #624905
Contractor CUPERTINO'PLUMBING INNG-Date 04/30/2018
X BLDG —ELECT X PLUMB
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
license is in full force and effect.
JOB DESCRIPTION:
REPIPE SFD (COPPER) - FULL
I hereby affirm under penalty of perjury one of the following two declarations:
t. 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 / 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: $4000.00
permit is issued.
APPLICANT CERTIFICATION
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
369 27 039
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 the granting of this permit.
WITHIN 18Q DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
1,
�'
Signature Date
Issued by: AbbyAygnde
OWNER-BUILDER DELI
Date: 01/03/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RF ROOF :
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
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)
z. 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:
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
performance of the work for which this permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
2. 1 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 arc Safety Code, Sections 25505, 25533, and 25534. 1 will
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
3. 1 certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
Zn
,
be deemed revoked.
Owner or authorized agent:
'
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
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,
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
ARC'HITECT'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.
Licensed
Signature Date
Professional
r
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT ® BUILDING DIVISION
90300 TORRE AVENUE - CUPERTINO, CA 95014-3255 misc
(408) 777-3,228 • FAX (408) 777-3333 • buitdincrtafcupertino.orq
ZING OMECHANICAL ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS 804'2)1r,+ l� Z.� APN # a- r
OWNERNA IE PHONE E-MAIL
Madan Yknuv a , ®1' °
STREET ADDRPS j CI STATE, ZIP FAX
i -I b e. fl i n Allam CONTACT -
CONTACT NAME
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STREET ADORES ''^I " ��'6 1 ® y All CITY, STA/•T�ZIP01lv�-
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0 OWNER 0 OWNER -BUILDER 0 OWNER AGENT II/CONTRACTOR 0 CONfRACTORAGENT ❑ ARCKMCT ❑ ENGINEER. ❑ DEVELOPER ❑ TENANT
CONTRACTORNANr'" ryor+j � Pl u r� b, .�SE NINIBEIij � j i p� Lj . $E Fn � BUS.I IC # j
COMPANY NAME �r
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ARCHITECT/ENGINEERNAME
LICENSE NUMBER
BUS. LIC#
COMPANYNAME
E-MAIL.
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE. OF 1457DUPLEX ❑ MULTI -FAMILY
BUILDING:. n COMMERCIAL
PROJECT INWILDLAND: ❑ YES
URBAN RNTERFACE AREA O
PROJECT IN
FLOOD ZONE
❑ YES
"I;k<0
IS THE BLDG AN
EICULFIRRROME?
❑. YES.
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DESCRIPTION OF WORK Cone
TOTAL VALUATION: ,`� RECELVED,13:
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owners beha . 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 buildin constmcti_on. I authorize representatives of Cupertino to enter the above-iide ed roperty for inspection purposes.
Signature of Applicant/Agent: iV" zi aDate: 1 7
INFORMA
MEPMiscApp 2011.doc revised 06121111