B-2018-1206 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1206
844 ROSE BLOSSOM DR CUPERTINO,CA 95014-4214(359 04 018) CONVECTEK
SUNNYVALE,CA
94085
OWNER'S NAME:
PHONE NO:(409)687-5754
LICENSED CONTRAC'TOR'S DECLARATION BUILDING PERMIT INFO:
License Class 5-24 Lie.#953068
Contractor CONVECTEK Date 10/31/2018 X BLDG ELECT_PLUMB
1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing X MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is fm full force and effect. JOB DESCRIPTION:
ADD(N)AC UNIT TO EXISTING FURNACE-BACK YARD
I hereby affirm under penalty of perjury one of the following two declarations:
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.
I, I 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: Valuation:$6000.00
V 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: Occnpancy'lype:
and state laws relating to building construction,and hereby authorize 359 04 018
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 WORI{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 a////./ Data 07/16/2018 Issued by:Jasmine Archbold
Date:07/16/2018
OWNER-RUILDER DECLARATION
I hereby affirm that I am exempt front the Contractor's License Law for one of the RE-ROOFS,
following live reasons: All roofs shall be inspected prior to any roofing material being installed.If.roof is
n. I,as owner of the property,or my employees with wages as their sole installed without first obtaining ai nepection,I agree to remove all new materials for
ompeusntion,will do the work,end the structure knot intended or offered for inspect:°°.
sale(Scc,7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec,7044,Business&Professions Code), Date:0 711 6/2 0 1 8
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER1. 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 which[his permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. 1 have and will maintain Worker's Compensation Insurance,as provided for by 1 have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the porfor mance of the work for which this California Health&Safety Code,Sections 25505,25533,aart 25534.1 will
permit is issued. maintain coce mplianwith the Cupertino Municipal Code,Chapter 9.12 and the
3. 1 certify that in the performance of the work for which this permit is issued,I n Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
material.Additionally,should I use equipment or devices which endt h co rdous
shall not employ any person in any manner so as to became subject to the air contaminants as defined by the Buy Area Air Quality Management District 1
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions o£the the Health&Safety Cade,Sections 25505,25533,nad 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked Owner or authorized agent:
APPLICANT CERTIFICATION Date:0 711 6/2 01 8
1 certify that I have read this application and state that the above information is CONSTRUCTION I ENDING 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 07/16/2018 Professional