B-2018-1169 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1169
7557 BOLLINGER RD CUPERTINO,CA 95014-4334(359 22 045) PELLE HEATING&
AIR INC
SAN JOSE,CA 95111
OWNER'S NAME:PARKER PARK C AND GAYLE B TRUSTEE DATE ISSUED:07/11/2018
OWNER'S PHONE: PHONE NO:(408)978-7060
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-20 Lic.#8.09887
Contractor PELLE HEATING&AIR INC Dale 10/31/2019 X BLDG—ELECT—PLUMB
1 hereby affirm that I am Recused under the provisions of Chapter 9(commencing X MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Cade and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE FURNACE-SAME LOCATION IN GARAGE;REPLACE AC
I hereby affirm under penalty of perjury one of the following two declarations: UNIT SAME LOCATION-LEFT SIDE OF THE HOUSE;
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 of the work for which this permit is issued.
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$3870.00
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 slate laws relating to building construction,and hereby authorize 35922 045
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 / _P-ate 07/11/2018 Issued by:Jasmine Archbold
Date:07/11/2018
OWNER-Rill DSR D!Cf.ARATION
I hereby affirm that I tun exempt train the Contractor's License Law for one of theRE-ROOFS•
following two reasons: All roofs shall he inspected prim to any roofing material being installed.Ira roof is
r. 1,as owner ofthe property,or my employees with wages as their sole installed without first obtaining an iospectimh,I agree to remove all new materials for
compensation,will do the work,and the sitacture is not intended or of of ed far inspection.
sate(So.7044,Business&Professions Code)
z. 1,as owner ofthe property,am exclusively contracting with hecnscd Signature ofApplicanL
contractors to construct the project(Sec.7044,Business&Professions Code). --Date:07/11/2018
1 hereby affirm under penalty of perjury one of'the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
a. 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 ofthe Labor Code,for the
performance ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials i equirements under Chapter 6.95 of the
Section 3700 ofthe Labor Code,for the performance ofthe work for which this California Health&Safety Code,Sections 25505,25533,and 25534.1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. I 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 any person in any manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
air conbuninants as defined by the Bay Area At,-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 betaine subject to the Worker's Compensation provisions of the the Haalth&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Data:07111/2018
1 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 AI2CHI'I'F.C'l"S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 07/11/2018 Licensed
Professional