B-2018-1135 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:13-2018-1135
11583 COUNTRY SPRING CT CUPERTINO,CA 95014-5116(366 51 052) PELLE HEATING&
AIR INC
SAN JOSE,CA 95111
OWNER'S NAME:RAHMAN AFROZA B TRUSTEE DATE ISSUED:07/05/2018
OWNER'S PHONE: PHONE NO:(408)978-7060
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C20 Lic.#809887
Contractor PELLE HEATING&AIR INC Date 10/3112019 X BLDG_ELECT_PLUMB
1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing X MECH LY RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in fall force and effect. JOB DESCRIPTION:
REPLACE FURNACE(SAME LOCATION)REPLACE AC UNIT(SAME
I hereby affirm under penalty of perjury one of the following two declaratlons: LOCATION)
r. 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 the work for which this permit is issued.
I have and will
maintain Worker's Compensation Insurance,as provided fmby
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.IT Floor Area: Valuation:$10693.00
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 366 51 052
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 180 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.
—�
Signature Date 07-5-2018 Issued by:Kim Dunbar
Date:07/05/2018
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
r. I,as owner of the property,or my employees with wages as their sole installed without frst 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 ofAppllcane
contractors to construct the project(Sec.7044,Business&Professions Code). Date;07-5-2018
1-hereb"filrar-under penullyafperjurj-mre-of-the-following tMree-declaratlons: ALLROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 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
perfamanco of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z lhave and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements udder Chapter 6.95 of the
Section 3709 of the Labor Code,for the performance of the work for which(his California Health&Safety Cade,Sections 25505,25533,and 25534.I will
permit is issued, maintain complhmeo with the Cupertino Municipal Code,Chapter 9.12 and the
s. 1 certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous
shall not employ n in an manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
p y any pease y J air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,ager making this certificate or 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 Cade,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent.
APPLICANT CEWTIFICA711ION Date:07-5-2018
I certify that I have read this application and state that the above information Is CONSTRUCTION LENDING 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 ARCBITECq' DECLARAT1oN
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 07-5-2018 Professional