B-2016-3008 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3008
210/6 GRENOLA DR CUPERTINO,CA 95014-1624(326 28 066) ATKINSON
CLIMATROLLERS INC
SAN JOSE,CA 95112
OWNER'S NAME: BORNER WILLY AND VRENI TRUSTEE DATE ISSUED:10/28/2016
OWNER'S PHONE:203-241-3501 PHONE NO:(408)294-6290
I_N i Id 'IA s 1' l_ ; t I i, BUILDING PERMIT INFO:
Lice se Class C-20 Lic.#258540
Con rector ATKINSON CLIMATROLLERS INC Date 12/31/2016 X BLDG _ELECT _PLUMB
I he eby 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
licen.a is in full force and effect. JOB DESCRIPTION:
ADD HEAT PUMP-BACK YARD .
I he eby affirm under penalty of perjury one of the following two 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.
j// JI have and will maintain Worker's Compensation Insurance,as provided for by
V, Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$6850.00
APPLICANT CERTIFICATION
I ce ify 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: Occupancy Type:
and state laws relating to building construction,and hereby authorize 326 28 066
representatives of this city to enter upon the above mentioned property for
insp ction purposes. (We)agree to save indemnify and keep harmless the
City ;f Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may ccrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Addi Tonally,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.
Sign ture e'..„,4h '�"
gDate 10/28/2016 Issued by:Abby Ayende
Date:10/28/2016
OWNER-BUILDER DECLARATION
I herby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOF'S:
follo ' g two reasons: All roofs shall be inspected prior`to any roofing material being installed.If a roof is
i. 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)
2. 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
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. HAZARDOUS MATERIALS DISCLOSURE
f. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of 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. 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
be deemed revoked. Owner or authorized agent: ii ( 4 t
APPLICANT CERTIFICATION "Date:10/28/2016
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
torr ct.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
relatg to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to en er upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to sa e 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 ill comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DELL TION
Code,Section 9.18. I understand my plans shall be used as public records.
r
SiSignature Date 10/28/2016 Licensed
g Professional
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M EP
1 1 GENERAL PERMIT APPLICATION
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COMMUNITY DOMPT =B
.0 .t F,„. TORRE AVENUES
GUPERTINOENTDEAR
,GAMENT 95014-3255
UILDING DIVISION
CUPt~R"CIN (408)777-3228•FAX(408)777-3333•buildinq ncupertino.orq MISC
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❑OWNER ❑ OWNER-BUILDER 0 OWNER AGENT iSt CONTRACTOR 0 CONTRACTOR AGENT ❑ ARCHITECT 0 ENGINEER 0 DEVELOPER ❑'TENANT
.RClpq.q�NAME,./y'���^y��1/�� 41/V �' ,�C/ LICEN " LIC �' BUS.LIC#
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Sl r AT„y��y1�„ Atitt �t y CITY STATE ZIP �J�• / ry.� !'//a� PHONE O , •
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A1ItCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC
CO'vIPANY NAME - - . ---, -
E-MAIL FAX -_ _
STET ADDRESS CITY,STATE,ZIP PHONE
USE OF 0 SFD or DUPLEX 0 MULTI-FAMILY PROJECT INT 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
DEL CRIPTION OF WORIA ) P t1,Y Na Yy (....414
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TOTAL VALUATION: 06-v. 12, [LRECI ZS�EI513Y f t( f,,
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Byimy signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property o .er's be alf. I have read this
apr lication 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 t• .wilding c nstruction. I authorize representatives of Cupertino to enter the above-identified prope for inspection purposes.
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Signature of Applicant/Agent: !I1 t Date: L V/' /' l
SUPPLEMENTAL INFORMATION REQUIRED R
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MEPMiscApp_2011.doc revised 06/21/11