12040156 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS; 10420 PINEVILLE AVE CONTRACTOR:SERVICE EXPERTS PERMIT NO: 12040156
HEATING&AIR
OWNER'S NAME: 11NG ZHANG 6984 SIERRA CT DATE ISSUED:04/27/2012
OWNER'S PHONE: 3988250 DUBLIN,CA 94568 PITON F.NO:(925)400-6024
io LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 0051111 F,RCLAL
License Class C Z U Lie.q S1057/ REPLACE FURNACE A/C &COIL SPLIT SYSTEM
.ATI q-67-1L
Conlractor�l,l Ql4 Uate
,l--�l U0Ll0"
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business At Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
1 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 whichthis permit is issued. Sq.FI Floor Area: Valuation;$7230
1 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
APN Number:36913040.00 Occupancy Type:
permit is issued. rr
APPLICANT CERTIFICATION
1 certify that I have mad this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN AYS OF PERMIT ISSUANCE OR
to building consimetion,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAY OM LAST CALLED INSPE 10
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the 9 7 /,
granting of this permit. Additionally,the applicant understands and will comply Issued by: �C L Dale:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signator O -_ __Daft l I All roofs shall be inspected prior to any roofing material being installed If a roof is
;,% installed without first obtaining an inspection,1 agree to remove all new materials for
' x inspection.
❑ OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
1 hereby affirm Thal I em exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1,as owner of the property,or my cnployees with wages as their sole compensation,
will do the work,and the stmc(ure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE;
construct the project(Sec.7044.Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safely Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safely Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District 1
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,S li ns 25505,25533,and 25534. y
Section 3700 of the Labor Code,for die performance of the work for which this
Owner or authorized agen O l/`—¢Gr Dale: —2?—(Z
permit is issued. X41
I certify(hat in the performance of the work for which this permit is issued,I shall
not employ any person inany manner so as to become subject to the Worker's
Compensation laws of Cal ifomo- IL atter making this certificate of exemption,1 CONSTRUCTION LENDING ACF.NC\'
become subject to the Worker's Compensation provisions of the Labor Code,I must 1 hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked, work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and stale 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 properly for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit,Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
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2008 Rrsiddrx6d Camplfance Forms March 2010
GENERAL PERMIT APPLICATION 1'1 E P
COMMUNITY:DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 MIS^
(408)T77-3228• FAX(408)T77-=•buildino(cDcuoerdno.or> ■V_
CUPERT{NO
1Zo� 61 scp
❑PLUMBINGG ' /®�MEa-[ANICAI: ELECTRICAL ❑NMCE r e/NEOOUSS
PROJEET ADDRESS ioYzt)� i✓IeI/l.!/ O
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OWNm NAME L/.`Tl A Pam /� ROO E-MAIL
E-MA
SIBFFTADDREj,g2,U �In 1/lw U'2 Cwr A P ( IYI(J /yUI� FAX
MP
CONTACT NAME - PRONE E-MAD.
STREETADDRESS CITY,STATE MP FAX
❑OWNER ❑ owNm-u=RR, ❑'OWNERAOErT cmmACma ❑CUNTRACIDRAtiENT Cl ARO01rwr ❑FNowFrs 0 DEVELOPER ❑'IfliAM -
CONTRACTOR NAME glUS7 ) D RUS.LIcs
COMPANY NAME &IVE-MM- FAX
STREET ADDRESS ' �' MO'byl Pp 9v:6� -�
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ARCHMC[/ENGDTMNAM1E - V@SE NLOMEt ROS.LICA
COMPANY NAME. E40JL FAX
STP-Wr ADDRESS CrIY,STATE.IIP FNONE
USE OF 1HSFO.DuFLEX ❑ MULTLFAMRY PROMCFw WaMLANO ❑ Y6 PPo]IFGfOR ❑YRS STFrE Calx:AN ❑YER
RUDDw2 �•-•••••••.'•�•, rDtaAN DfTFRFA�Avc• ❑NO FLOOD ZONE ❑NO EODFA HOIKET 0N
DESCRIMON OF WORK .
It f sqs wt
TOTAL VALUATION: 1030, 00 um m By: Ems !✓
By my sipn below.I certify to each of dm fDncwmg: I=the Pmpety awoa ar sothormd agar[to as un the property owaa's behalf 1 have read dm
application and the kdocmatlaa I have provided is cmieeQ bave read dre Description of Wart and verify it is accm-dft- 1 agree to con ply with an applicable lod
otdmaaca and state laws relating to - 'aa.I of Caperdao to eater the above-identified property fm mypecam parvo
Signature ofAppb®t/Agentr Date: "l 7,7-1 Z
SU"L EMENTAL INFORMATION REQUIRED OFFICE USE ONLY
m OVElt-THElOUNTEt
❑ 9"XFSS
U
❑ STANDARD
u
❑ L&RCE
❑ MAJOR
MEPM=App 20I Ldoc revised 06/21/11