B-2018-0652 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0652
10190 PARKWOOD DR CUPERTINO,CA 95014.1479(326 27 037) THERMAL
MECHANICAL
SANTA CLARA,CA
95054
OWNER'S NAME:AVERY GLENBROOKLP DATE ISSUED:05/07/2018
OWNER'S PHONE:650-961-8330 PHONE NO:(468)988-8744
LICENSED CONTRAC'TOR'S DECLARATION BUILDING PERMIT INFO:
License Class C4.C10.C20.C36.&C38 Lia#256057
Contractor THERMAL MECHANICAL Dale 01!31/2020 X BLDG_ELECT_PLUMB
MECH X RESIDENTIAL COMMERCIAL
1 hereby xftirm tin[1 am licensed ander the provisions of Chnpter 9(commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and affect. JOB DESCRIPTION:
BUILDING 054-(N)HOT WATER SYSTEM&ENCLOSURE;
I hereby affirm under penalty of perjury one of the following two declarations: UPGRADES AND REPAIR OF EXISTING BUILDING SERVICES
r. I have and will maintain a certificate of consent to self-insure for Workers
Compensation,as provided for by Section 3700 of the Labor Code,for the
Y have ad w of the work for which this permit is issued.
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
permit is issued. Sq.Ft Floor Area: Valumina:$50000.00
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 AIN Number: Oecupmrcy'I'ype:
and state laws relating to building construction,and hereby authorize 326 27 037
representatives of this clty 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 ie Cl pe tiro unicipal code,Section 9.13. 180 DAYS FROM LAST CALLED INSPECTION.
Signature / Data 05-07-2018 Issued by:Kim Dunbar
Data:05/07/2018
OWNER-Bl"tMER 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 prim to any roofing material being installed.If a roof is
r. 1,us o nen of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended m offered for inspection.
sale(S-7044,Business&Professions Code)
1. 1,as owner ofthe property,am exclusively contracting with licensed Signature ofApplicurn:
contractors to construct the project(Sce.7044,Business&Professions Code). Datc:0547-2018
1 hereby affirm under penalty ofperjury one a]the following three declarations: pLL ROOF COVERINGS TO BE CLASS"A"OR BETTER
a. 1 have and will maintain a Certificate ofCoisent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Codc,fur the
performance of due 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 Imre read the ha on-dons materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for One performance of the 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(10 should I store or handle hazardous
shall not employ an n in any manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
P Y Y person y ma J air contaminantsas defined by the Bay Aran Air Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of will maintnin compliance with the Cupertino Municipal Code,Chnpter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Henith&Safety Cade,•f ns 05,25533,and 25534.
Labor Coda,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:05-07-2018
I certify that I have read this application and state that the above Information is CONSTRUCTION LENDING GCNCY
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 IiaURI-,
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 ARCIUTECT S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 05-07-2018 Licensed
Professional