12070171 CITY OF CUPERTINO 13UILDING PERMIT
BUILDING ADDRESS: 20058 PACIFICA DR CONI'RAC'MR:CHOICE MECHANICAL PEIRMIT'NO: 12070171
OWNER'SNAME: GARNER DELANO DTRUSTEE 4720 FALSTAFFAVE DA'Z'E ISSUED:07/23/2012
OWNER'S PHONE: 4082973318 FREMONT,CA 94555 I'I ION.NO:(510)797-1289
i
❑ LICENSED CON I'RACI'OR'S DIiCLARAT'ION BUILDING.PERMIT INFO: BLDG r ELECT r PLUMB 1—
LicenseClass r t0 If Y4 1-ice4 ""-, 3V 5y z 9-6 DIECH r RESIDENTIAL r COMMERCIAL r
Contractor Date 7/7.�--//ii-
1 hereby'affirm lhai 1 nm licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE AND REPLACE THE FURNACE,
(cummenci ng with Section 7000)of Division 3 of the Business S Professions
Code and that my license is in full force and effect.
1 hereby affirm under penaltyof perjury one of(lie fulloa'ing mo declarations:
I have and will maintain a cenilicate of consent to set Ginsure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,I'm the
performance ofthe work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valualion:$2500
Section 3700 of the Labor Code,for the performance of to work fornvhich[his
permit is issued.
APN Number:36928027.00 Occupmncy'IYpc
APPLICANT CERT'IFICAT'ION
I certify that I have read this application and slate 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
PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned progeny for inspection purposes. (We)agree to save
indemnity and keep hamdess the City ofCupenino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accme against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands mrd will compl}'
with all non-point source regulations per the Cupertino Municipal Code,Section /' //
9.18. Issued by: r��n/ Hfl7xif Date: �•�3•Ja-
Signature DateDZ.
❑ 0%VNER-BHILDFR DECLARATION RF:ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
hereby affirm that I inn cvcmpt from the Contractor's License Lao for one"I' installed without first obtaining am inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the properly,or my employees with wages as their sole compensation,
mrill do the work,and[he structure is not intended or offered for sale(Sce.7044,, Signature of Applicant: Date:
Business S Professions Code)
I,as owner of the properly,am exclusively contracting with licensed contmetors to
construct the project(Sce.7044,Business'& Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR RE ITER
I hereby affirm under penally of perjuy one of the following three
declarations: IIA%ARDOUS\IATERIAI S DISCLOSURE
I have and will maintain a Cenifica[e of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health S Safety Code,Sections 25505,255334 and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Jlanicipal Code.Chapter 9.12 and the health S
I have and will maintain Worker's Compensation Insurance,as provided Ibr by Safeiv Code.Section 25532(a)should 1 store or handle hazardous material.
Section 3700 of'Ihe Labor Code,for die performance of the work for which this Additionally,should 1 use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality'lilanagement District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
I certify that in the perImulance of doe work for which this permit is issued,1 shall Ilcnl[h J Safety Code,Sections 25505.25533.and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation Imes of Cali fomia. If,after making this cenificate ofexenmption,I Oi,ner r authorized agent:
become Subject to the Worker's Compensation provisions of the Labor Code,I must �Z
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUC`1'I0N LENDING AGENCY
,UTI-ICAN'f CP:R'1'IPIC.\"I'ICIN I hereby affirm[hal there is a construction lending agency for the performance of work's
I cenify that I have read this application and stale that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct. I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupenino against l iabilitics,judgnments,
costs,and expenses which may accme against said Ciq in consequence of[he ARCI BT'ECI"S DECLARATION
granting of[his permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupenino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
GENERAL PERMIT APPLICATION M E P
COMMUNITY DEVELOPMENT DEPARTTvIENT• BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-325-5
MI
/� /�
GUPERTINO (408)777-32288�- FAX(408)777-3333 • building0cuoerino.org v\ /v-
❑PLUh®ING 05J CHANICAL ❑ELECTRICAL ❑NUSCELL.ANEOUS
PROJECT ADDRESS 'Z Sof Xc1,r/GA /-
APN».�� a� �a7
OWNER NAME -244o, -I A 14 PY.ONE56_z E-
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STREETADORESS =. STATa - PAX
Zego.5'f nA�I�1 0. P r .�2 ., D e%
CONTACT NAME 7 �I/ Gad PHONF7,,O 15717 5-04e,,s E-MAIL
srREr-ADDREss Z� 1a-✓y CITY.srATSTATE. �� FAXS e /Z$'
❑ OWNER ❑ owNER-alm.pR ❑ OWNER AGEYT CONTRACTOR ❑CONTRAC ORAGENT ❑ ARCDRECT ❑ENGNEEt ❑ DEVELOPER- ❑ TENANT
CONTRACTOR NAE2Oy C r LITE
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GDMPA.`1Y NAT.¢ L ` E MAB. 7 C'r FAX
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S=ADDRESS CITY,STATE,ZIP PHONE
G 7ZD ' 'dJvnt
ARC TIMC ENGLN'EEt NAME �. LICENSE NUMBR I BUS.LIC p
COMPANY NAME' E-MAIL FAX
STREET ADDRESS CITY,STATE ZIP I PHONE
USE OF SFO a OUPLEC ❑ MULTi-FAMILY PROTECT IN WH.DLUID ❑ YES PROJECT N ❑ YES IS THE BLDG AN ❑ YES
B=NG: Y❑COM.WERCLLL URBAN 74TERFACE AREA NO I FlDODZONE NO I MCHLER HO.1ff' .O
DESCR=ON OF WORK
TOTAL VALUATION: '�. �� % RECEIVED BY: �C
ry
By my signature below,I certify to each of the following: I am the pruperry owner or autheriud agent w act an the property owner's behalf. I have read this
application and the imormation I have provided is correct. I have read the Desc iption of work and verify it is accurate. I agree io comply With all applicable local
ordinances and sate laws relating m building cone cdon. I aurhariw representatives of Cupertino to inter the above-i nd6cd pe,-j for inspection pui�uses.
Signature of ApplicanHAgeac Dam:
SUPPLEivAL[N AITION REQUIRED OFFICE USE ONLY
y OVER-THE-COUNTER
t
❑ EXPRESS
U
❑ STANDARD
U
❑ LARGE
❑ pIAJOR
AiEP.Nsc4pp_2011.doc revised 06/21/11