BLD-2021-1904BUILDING PERMIT
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 10649 MORENGO DR Cupertino APN: 375 34 012 PERMIT NO: BLD-2021-1904
OWNER'S NAME: OWNER'S PHONE: Not Provided
CONTRACTOR: PACIFIC POLYMERS INC DBA AMERICAN FOAM EXPERTS, P O BOX 190 HERALD CONTRACTOR PHONE:
DATE ISSUED 9/23/2021 1:48:30 PM ISSUED BY:VALUATION: $21830.00
JOB DESCRIPTION
1) Gravel Removal/Disposal 2) Drain/Downspout Installation 3) Edge Metal Prep/Installation 4) Apply Polyurethane Foam 5) Apply Base Coat 6) Apply Top Coat
LICENSED CONTRACTOR INFORMATION
CONTRACTOR: PACIFIC POLYMERS INC DBA AMERICAN FOAM EXPERTS
LICENSED CLASS: C39 ROOFING, C33 PAINTING AND DECORATING
LICENSED NO: 969486
EXP DATE: 01/31/2022
I 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 penatly of perjury one of the following three declarations:
1 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.
2 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.
3 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. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, l must forthwith
comply with such provisions or this permit shall be deemed revoked.
I understand and agree that I am electronically signing and filing this application and that checking the box below has the same legal effect as manual signature. I also
understand that I have the option of filing a paper copy of this application with a manual signature but have chosen instead to file this application electronically.