BLD-2020-148411/4/2020
CITY OF CUPERTINO BUILDING PERMIT
BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 22888 CRICKET HILL RD Cupertino 1
APN: 342 35 017
PERMIT NO: bld-2020-1484
OWNER'S NAME: GHOSH INDRANEEL AND SARMISTHA TRUSTEE
OWNER'S PHONE: 4082427006
DESCRIPTION
INSTALL NEW AC UNIT
LICENSED CONTRACTOR DECLARATION
CONTRACTOR: M B K T CORP dba PACIFIC COAST LICENSED CLASS: (.,. j10 e� 4) LICENSED NO: 863274 EXP DATE: Via://2v 1
ELECTRIC -HEATING & AIR Could not retrieve LP info. Could not retrieve LP info.
1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license Is In full force
and effect.
I hereby affirm under penally of perjury one of the following three declaraffons:
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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 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.
I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws
of California.
this
lf, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or
permit shall be deemed revoked.
HAZARDOUS
MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the n':) Health & Safety Code Sections 25505 25533 and 25534. I will maintain compliance with the
Cupertino
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Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices
which
the
emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
Health & Safety Code, Sections 25505, 25533, and 25534.
EPA
LEAD -SAFE DISCLOSURE
❑
An EPA Lead -Safe Certified Renovator will be responsible for this project.
Certified
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Firm Name: [ 1 Firm Certification No: i 1
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No EPA Lead -Safe Certified Firm is required for this project.
CONSTRUCTION LENDING AGENCY
I hereby affirm under penalty of perjury that there is a construction lending agency for the performance of the work which this permit is issued (Section 3097, Civil Code).
.
Yes
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No
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Lender's Name: g 1 Lender's Address:; 1
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APPLICATION 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 and state laws relating to building
construction, and hereby authorize 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, judgements, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant
understands and will comply with all non -point source regulations per the Cupertino Municipal Code. Section 9.18.
Signature:
g
Every
://apps.cupertino.org/Accela/BLD-Sign-Permit.aspx?AccelaUser=ONETIMESIGN&OTK=JT3KriowI l SJKGXeLh616IhSqtrtiK46oFgKmopW0a8Si81... 1 /1