B-2018-0881 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR; PERMIT NO:B-2018-0881
10274 PARKWOOD DR APT 3 CUPERTINO,CA 95014-1513(326 27 036) THERMAL
MECHANICAL
SANTA CLARA,CA
95054
OWNER'S NAME:AVERY GLENBROOK LP DATE ISSUED:05/23/2018
OWNER'S PHONE:650-961-8330 PHONE NO:(408)988-8744
LICENSED CONTRAC'TOR'S DECLARATION BUILDING PERMIT INFO:
License Class C4.CIO,020.C36.&C38 Lic.#52 6057
Contractor THERMAL MECHANICAL Date 01/31/2020 X BLDG X ELECT X PLUMB
I herebyaffirm that I am licensed tinder the provisions of Chapter 9 X MECH X RESIDENTIAL_COMMERCIAL
a prov p (commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
BLDG 7 UNIT#3-(N)AC UNIT;REPLACE FURNACE(SAME
I hereby affirm under penalty of perjury one of the following two declarations: LOCATION);(N)WASHER/DRYER HOOK-UPS;REPLACE
II have and will maintain a certificate of consent to self-insure for Worker's ELECTRICAL PANEL(70 AMP)(SAME LOCATION);(N)GAS LINE
Smpensation,as provided for by Section 3700 of the Labor Code,for the FOR STOVE;REPLACE OUTLETS(10);REPLACE LIGHT
:9ormance of the work for which this permit is issued. (BATHROOM);(N)(1)EXHAUST FAN(BATHROOM)
ave and will maintain Worker's Compensation Insurance,as to for by
'ction 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$20000.00
APPLICANT CERTIMCATION
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 27 036
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 05-23-2018 Issued by:Kim Dunbar
Date:05/23/2018
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for one of the RE-ROOFS,
following two reasons: All roofs shall be inspected in to tiny rooting material being installed.I£a roof is
1, I,as o� r of the property,o my employee with wages as their sole installed Without first obtaining an inspection,l agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sca7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sce.7044,Business&Professions Code). Date:05-23-2018
1 hereby am,-.under penalty all one of the following flow decimations: ALL ROOF COVERINGS TO DR CLASS"A"OR BETTER
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 but which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by 1 have read the hazardous materials requirements under Chapter 695 of the
Section 3700 of the Labor Code,Rothe perfornwuce of the work for which this California Health&Safety Code,Sections 15505,25533,and 25534.1 will
permit is issued, maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. 1 certify that in the performance of the work far isHealth&Safety Code,Section 25532(x)should I store or handle lra—dous
which this permit is sued,1 naterial.Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so us to become subject to the air contaminants its defined by the Bay Arca Air Quality Management District I
Worker's Compensation laws of Californis.If,after making this certificate of w111 ambind.compliance with the Cupertino Municipal Code,Clmpter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Se ons 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 CERMFICATION Date:05-23-2018
I certify that I have read this application and state that the above information is CON'S'1'IiUCTION 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 ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 05-23-2018
Professional