B-2016-3206 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3206
909 PROVIDENCE CT CUPERTINO,CA 95014-4028(356 11 052) RANDO AAA HVAC
INC
SAN JOSE,CA 95125
OWNER'S NAME: MARKS DELIAM TRUSTEE DATE ISSUED:12/05/2016
OWNER'S PHONE:650-303-1592 PHONE NO:(408)293-4717
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C43 Lic.#768871
Contractor RANDO AAA HVAC INC Date 09/30/2017 X BLDG _ELECT _PLUMB
X MECH X RESIDENTIAL_COMMERCIAL
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. JOB DESCRIPTION:
REPLACE FURNACE(SAME LOCATION)
I hereby 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.
iv . 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:$3628.00
APP!T ANT_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 construction,and hereby authorize 356 11 052
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 IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the appitcant understands and will comply with all non-point
source regulations ''erthe •ertino Munic'eal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature ',f r/ f � Date 12/5!2016 Issued by:Kim Dunbar
t,' Date: 12/05/2016
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from 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
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree toremove 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:12/5/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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 Municipal Code,Chapter 9.12 and the
Health&A Safety Code,Section 25532(a)should I store or handle hazardous
3. I certify that in the performance of the work for which thus permit is issued,I material. Additionally,should I use equipment 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 Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the upertino Municip• Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cod.,Sec ons 25505,2J33,and 25534. •
Labor Code,I must forthwith comply with such provisions or this permit shall /
be deemed revoked. �
Owner or authorized,z
APPLICANT CERTIFICATION Date:12/5/2016
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.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, 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 12/5/2016 Professional
i
„,..
GENERAL PERMIT APPLICATION mE p
COMMUNITY DEVELOPMENT DEPARTMENT*BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
M ISC
CUPERTIN (408)777-3228•FAX(408)777-3333•buildinciacuqertino.orq
O-
.,
0 pLumBING NmEcHANIcAL EDELEcTRTAL El MISCELLANEOUS
. , ,
PROJECT ADDRESS gal prov)rIcriced, cattle. APN# 35 1.0 ,,....... I 1 .........
OWNERNAME 4,00 ard izi to..., 0 064)3 0;....1 5q2..... E-MAIL
STREET ADDRES9 y.)1 protijacricc„ ci- c(10:irl' ,E..LZAPN...e-si rd ri .t..4,,,,it 1 j PAX
.
1 1k-fit-;” `.1 ---1‘-li 7
-HONE I 57r-) E-MAIL
CONTACT NAME ' '''' ) p....:1 1,50-)D03_ z
10,1/41
STREET ADDRESS CI 09 0,,4_,...1„,m,„,,,,,, (74,_ enAsistico.zip. :•„,.. 0 ce q 5-0 1 Lt,..,FAX
" Lit•-•*/ k-4 ' ----"' -I-1"
0 OWNER 0 OWNER-BUIL)ER. 0 OWNERAGENT Pal CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT
.
CONTRACTOR NANIEU irn go In d 0 LICENSE NUMBER'— 1 1 LICENSE Tri43 i cello BUS,LIC# 061D
COMPANY NAME iv4 Furl)ac
5C, E-MA
li , ' 1.**11‘_.•• ,1,• 0Ke„,017,4A11 i
STREET ADDRESh i 2 sivi ` "4/„,,,.. Il 1 CITK-STAT E,ZIpi
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ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.Ll C 47
-----
COMPANY NAME E-MAIL FAX
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STREET ADDRESS ciTY,STATE,ZIP PHONE
USE OF K SFr)or Duplex 0 Multi-Family PROJECT IN WILDLAND PROJECT IN
STRUCTURE: 0 Commercial
URBAN INTERFACE AREA 0 Yes 0 No FLOOD ZONE 0 Yes 0 No
DESCRIPTION OF WORK
f"\ L1 0)0.C6 iCnet.0 '''' '''' '. ,. dji 't -_ C.. iif, - .
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,REcavED pY.,;• .igik:; ;,,t _.,,::,,,'L 'i,-:,', .;.....,;,1.,.'.i:4',',,,.:;:.'.i''',. '::;'"!.'
------ /.
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By 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 behalf,I have read this-
application and the information I have1:b.4i .. is correct. I have read the Description of Worlc and verify it is accuinte. I agree to comply with all applicable local
ordinances and state laws relating to linklin4 ...ion. I a.,iorize representatives of Cupertino to enter the above-id ritifie,d property for inspection purposes..
Signature of Applicant/Agent: , 1 t, 0,i, "All dp,______Vat , Date: a' 2-'1 1 '
SUPPVENTALINFORIvIATION REQUIRED ! ''.'ic;,,:-..- :-bi-kit.Et:i$00,N.LX:i:,;'-,s,
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