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B-2016-3007 CITY OF CUPERTINO BUILDING PERMIIT BULLING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3007 19351 CALLE DE BARCELONA CUPERTINO,CA 95014-3403(375 04 008) ATKINSON CLIMATROLLERS INC SAN JOSE,CA 95112 OWNER'S NAME: CHUA THAI CHENG DATE ISSUED:10/28/2016 OWNER'S PHONE:408-332-8028 PHONE NO:(408)294-6290 i r 1. 1 t' 1 =-t. I i, BUILDING PERMIT INFO: Lice se Class GENERAL BUILDING CONTRACTOR Lic.#258540 Cent actor ATKINSON CLIMATROLLERS INC Date 12/31/2016 X BLDG _ELECT _PLUMB I her•by affirm that I am licensed under the provisions of Chapter 9(commencing X MECH X RESIDENTIAL_COMMERCIAL with ection 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: REPLACE FURNACE(SAME LOCATION) I her by affirm under penalty of perjury one of the following two declarations: 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 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:$3600.00 APPLICANT CERTIFICATION I certify that I have read this application and state that the above infer i ation is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type: and tate laws relating to building construction,and hereby authorize 375 04 008 representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK I$NOT STARTED may ccrue againstsaidCity in consequence ans of the hg this 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. _Sgnature rte__ __ Date 10/28/2016 Issued by:AbbyAyende Date: 10/28/2016 II Ah! t-1 JI I II ; 114 ,k I her-by affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: folio ,g two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is I,as owner 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 or offered for inspection. sale(Sec.7044,Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:10/28/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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. HAZARDOUS MATERIALS DISCLOSURE I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95of the Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534. ' Labor Code,I must forthwith comply with such provisions or this permit shall - r be deemed revoked. ner or authorized agent: /' r �l/�/v� APPLICANT CERTIFICATION Date: 10/28/2016 I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY corre t.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, judg ents,costs,and expenses which may accrue against said City in Lender's Address cons quence of the granting of this permit. Additionally,the applicant understands and , comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECL TION Codei;Section 9.18. I understand my plans shall be used as public records. Signature Date 10/28/2016 Licensed Professional ,r,,,,,,, GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION r.J�,�\ 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 ,.,I (408)777-3228•FAX(408)777-3333•buildinq aC�cupertino.orq MISC ❑PLUMBINGrMECHANICAL El ELECTRICAL Iii MISCELLANEOUS PI IOJECT ADDRESS 1 9 3 5 L Alq...„ 0,„, , ��1 A/c„,,,,,(,N# I5 0(4 V C OWNER NAME Cl 11.cq �„ aril/ /�', vo\ PHONE Lag......:33 z^", t �. STtEETADDRESS bb ' "5 5 ( \ICck, (I\.✓P�..f.. ✓ZZJP 1 .." FAX JA/97& 7S ) � CONTACT NAME p 0 4L;f tl leA PHONE Y10 i '`? t 6/1 Eo E- STIEET ADDRESS r ( ( fJ f o . CITY,STATE,ZIP L.154.---:'t)03 151,1 2_ FAX ❑OWNER ❑ OWNER-BUILDER 0 OWNER AGENT CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT Atifekg CONTRACTOR NAME LICENSE NUMBER 2{"F75 0 LICENSE TYPECID BUS.LIC# 2si 1 ,'1 II . -9 / 7 o. i � �f%. �7 `-11 0.l /01 `>CONIPANYNAME Vot V4 f" EMAILII v FAX ,,,,,ii ST2EET ADDRESS �J7 O - �r `pj 1�J g (( / �//} U V 7 CITY,STATE,ZIP ''L.i l�t1 �'./t�G G.-. PHONE jam,( J Z / 1`°' ARCHITECT/ENGINEER NAME Y LICENSE NUMBER BUS.LIC##f X43 ,4:::-,7_577,0 C) COMPANY NAME E-MAIL FAX I STET ADDRESS CITY,STATE,ZIP PHONE USE OF 0 SFD or DUPLEX 0 MULTI-FAMILY PROJECT IN WILDLAND 0 YES PROJECT IN 0 YES IS THE BLDG AN 0 YES BUILDING: 0 COMMERCIAL { URBAN INTERFACE AREA 0 NO FLOOD ZONE 0 NO EICHLER HOME? 0 NO DESCRIPTION OF WORK / 1,e ( _ TOTAL VALUATION:4 3 A. !rJ RECEIVED BY: Coi \ 1., B31 my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's beha f I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to.uiiding c struction. uthor'ze representatives of Cupertino to enter the above--dentifed property for inspection purposes. Signature of Applicant/Agent: % e� Date: �U t 1. 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