B-2016-3110 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3110
924 NOVEMBER DR CUPERTINO,CA 95014-4121(362 13 032) ON-TIME AIR
CONDITIONING&
HEATING INC
PLEASANTON,CA
94588
OWNER'S NAME: HOSODA MORRIS AND LOUISE M TRUSTEE DATE ISSUED:11/14/2016
OWNER'S PHONE:408-252-4105 PHONE NO:(925)444-4444
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-20:C-36 Lic.#817040 `
Contractor ON-TIME AIR CONDITIONING&HEATING INC Date 09/30/2017 X BLDG _ELECT PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing X MECH X RESIDENTLAL,_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE FURNACE(CLOSET),A/C(BACK YARD)AND DUCT
I hereby affirm under penalty of perjury one of the following two declarations: WORK(40 FT)
1. I have and will maintain a certificate of consent to self-insure for Worker's
a
Compensation,as provided for by Section 3700 of the Labor Code,for the
ifperformance of the work for which this permit is issued.
i. 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:$20200.00
APPLICANT 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 APN Number: Occupancy Type:
and state laws relating to building "•nstruction,and hereby authorize 362 13 032
representatives of this city to ent- upon the above mentioned property for
inspection purposes. (We)agr-- o save indemnify and keep harmless the
City of Cupertino against liabili, ,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City' onsequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant u •:stands and will comply with all non-point
source regulations per the ierti Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 11/14/2016 Issued by:AbbyAyende
- ligr
Date:11/14/2016
I hereby affirm that I am exe..3 om the Contractor's License Law for one of the RE-ROOFS:
following 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:11/14/2016
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
2. 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 M,.'ci ral Code,Chapter 9.12 and the
Health&Safety Code,Section 25532(a). o i I store or handle hazardous
s. I certify that in the performance of the work for which this permit is issued,I material. Additionally,should I use equi r'men or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay/ ea•' Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cu!ertin. unicipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code, '' , 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall, ��Y
be deemed revoked. Owner or authorized agent: f
APPLICANT CERTIFICATION Date:11/14/2016 1 i/
I certify that I have read this application and state that the above information is it .Ii I.
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a const don lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is iss e (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, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant understands
ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
Signature Date 11/14/2016
.2)-7-06—NO
GENERAL PERMIT APPLICATION ME
P
VCOMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
-tfg, 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228• FAX(408)777-3333•buildinq(acupertino.orq 1 I S C
CUPERTINO
PLUMBING ❑MECHANICAL ❑ELECTRICAL ❑MISCELLANEOUS
PROJECT ADDRESS fu� i'l,(_ �¢ ®® �//_ '�/�ry
5g NeUatr sl Dhl Va' DPN# ✓ a✓ ,. 6_052_
OWNER NAME eweHilJiy 9
c_2(,/ E-MAIL
STREET D SS CITY,STATE,ZIP FAX
�}t�AD1 ( j al,L145eti Aid C-4 f U/ 4
CONTACT NAME
e4911)5-7s. E L
>N� t� c. L-�- �2 „frizz_ 7, re tocQ* 4,d-{-.
DCI u Dlv e'O it l i'i�C Lz. 0%,,,,),„sjt IP t q‘......19 Q, 1FA &)
(J41(/ VISI,
IDOWNER ElOWNER-BUILDER -❑ OWNER AGENT Yel CONTRACTORl CONTRACTOR AGENT ElARCHITECT ElENGINEER 0 DEVELOPER. ❑ TENANT
C N_Al 0 Irkic LICENSE NUMBER)'7 o cst
V s` LICA S�E�TYPF�3 BUS.LIC# 3
COMPANY NAME E-MAIL 4 mss/ (' FAX
STREET ADDRESS CITY,STATE,ZIP 7OHON
�0OM Cvia6 '' ?c,C4c�rv+J � 4-L1� ATI?) `lV4 141-1C-ii,
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF rrg SFD or DUPLEX ❑. MULTI-FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑'YES IS THE BLDG AN 0 YES
BUILDING: COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑NO EICHLER HOME? El NO
DESCRIPTION OF WORK �II
/1 /Q (tG /_ v6 ) n„ �y dry_
_�, n�� � \ /
1411 fiv C t ri ✓r.1 i Wore 1- ---
•
r
TOTAL VALUATION: b 1 'Ytc9
RECEIUEI7 13:Y::Y: 011IN
'ay
By my signature below,/ I certify to each of the following: I se property owner or authorized agent to act on the property o er's be al£ I have read this
application and the information I have provided is correct. I 4. e read the Description of Work and verify it is accurate.I agree to comply with-all applicable local
ordinances and state laws relating to building constru , ,. thorize representatives of Cupertino to enter the above-Mr ntifie roperty for inspection purposes.
Signature of Applicant/Agent: 1 ' Date: II P L /6
SUPPLEMENTAL I • ATION REQUIRED = ;oxc Uso�Lx
OVER411E-COUNTER
0 EXPRESS y,
0 STANDARD F',,
" ❑ LARGE= i
0 MAJOR:
NIEPMiscApp_2011.doc revised 06/21/11
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