B-2018-0646 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0646
10204 PARKWOOD DR CUPERTINO,CA 950144539(326 27 037) THERMAL
MECHANICAL
SANTA CLARA,CA
95054
OWNER'S NAME:AVERY GLENBROOK LP DATE ISSUED:05/07/2018
OWNER'S PHONE:650-961-8330 PHONE NO:(408)988-8744
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C4 C10 C20 C36&C38 Lic.#256057
Contractor THERMAL MECHANICAL Date 01/31/2020 X BLDG ELECT_PLUMB
1 hereby affirm that 1 um licensed corder the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license b infull force and effect• SOB DESCRIPTION:
BUILDING 457-(N)HOT WATER SYSTEM&ENCLOSURE;
1 hereby affirm under penalty of perjury one of the following two declarations: UPGRADES AND REPAIR OF EXISTING BUILDING SERVICES
i. 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
p formauce.£the work for which this permit is issued,
h ve and will maintain Worker's Compensation Insurance,as provided far by
action 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Fr Floor Arca: Vitiation:$SOo00.00
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 326 27 037
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 tl cu lino unicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature .*° Data 05-07-2018 Issued by:Kim Dunbar
Date:05/07/2018
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one at the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing anterial being installed.If a roof is
r. 1,as ownr eof the property,o my employees with wages as their sole installed without fust obtaining an inspection,I agree to remove all new materials for
oiopenssdon,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
z I,as owner ofthe properly'san exclusively contracting with licenser) Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code), Date:05-07-2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO RE CLASS"A"012 BETTER
i. I have and will maiumin a Ceffif..I.of in 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
z. I 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&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued. m aintain compliance with the Capin thin Municipal Code,Chapter 9.12 and the
3. 1 certify that in the performance of the work for which this perait is issued,I Health&Safety Code,Section 25532(a)should I store.r handle hazardous
shall rat employ any pars.,,in any manner so as to become subject to the nate rial.Addifimudly,should I use equipment or devices which exit hazardous
antionnim is as defined by the Bay Aron 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 fhe Heulth&Safety Code,Sections 25 O5,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be teemed revoked, Owner or authorized agent:
I APPLICANT CERTIFICATION Date:05-07-2018
certify that have read fhis application and state that the above information is CONSTRUCTION
correct.I agree to comply with all city and county ordinances and stale 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 ARCHIT'ECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 05-07-2018 Licensed
Professional