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B-2017-0013 • CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0013 20188 MERRITT DR CUPERTINO,CA 95014-2011(316 33 099) ATKINSON CLIMATROLLERS INC SAN JOSE,CA 95112 OWNER'S NAME: ZAMARIAN DARIO AND BIANCHINI GIUSEPPINA DATE ISSUED:01/04/2017 OWNER'S PHONE:408-255-1440 PHONE NO:(408)294-6290 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C-20 Lic.#258540 Contractor ATKINSON CLIMATROLLERS INC Date 12/31/2018 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. f 2: I have and will maintain Worker's Compensation Insurance,as provided for by I Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$5400.00 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 construction,and hereby authorize 316 33 099 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 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. Signature ''GG' Date 1/4/2017 Issued by:AbbyAyende Date:01/04/2017 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 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:1/4/2017 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 3. 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,Sectionsns225505,25533,and 25534. Labor Code,I must forthwith comply with such provisions'or this permit shall �� %b�`' be deemed revoked. Owner or authorized agent: APPLICANT CERPIF'ICATION ' Date:1/4/2017 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, judgments,costs,and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code,Section 9.18. I understand my plans shall be used as public records. Signature Date 1/4/2017 Licensed Si 9 Professional \t /i: GENERAL PERMIT APPLICATION M E P COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION /.,,,.,u,� 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 lvi I (408)777-3228•FAX(408)777-3333•buildinq cupertino.orq S CUPERTINO C ❑PLUMBING MECHANICAL ElELECTRICAL_ ❑MISCELLANEOUS PROTECT ADDRESS 2Q ' • A/2rrT- 9c 1414' ' ' OCt( OWNER NAME +\�,rt5iAesrA 3 Q )� PHONEL/I�8r/�� 1L14 0 EMAIL STREET ADDRESS 2 d I t� g .r CITYISV TQ��y[[�� c /l 1 J Q jt1 FAX Y(��Q{,/�I� © 1 Pffj ggq frV�i�.' Ef I 'IT ^ 7 1 �n CONTACT NAME f/ ", V'n 12cinkd PHONE(,/n Q''/}�� 1 Q EMAIL 1 /o y1 _ j 're LI L'i� (_ r.l.Y'w STREET ADDRESS 11"'f) I�r��. 14 CITY,STATEn.IPJ Q,-�,, V s 1 1511'2-,-'l:'�l FAX Vl�}��/ +J(r 11 -t7 ❑OWNER 0 OWNER-BUILDER 0 OWNER AGENT CONTRACTOR 0 CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT CONTRACTOR NAME 9 / 0,„/,-.61 f�^l�1�/ LICENSE NUMBER/2_,515.4 0 LICENSE TYPE 62%!1 BUS.LIC# (LiCOMPANY NAME U� L '^ )�` D 1.1 E MAII. / FX STREET ADDRESS L �� IN I] �J-J�q/ ,� CITY,STATE,ZIP 1 l�/C1,71 '�� �Y� (��j�,��,'// R n ~t ✓ 1! pI y\J� t„� �! r PHONE - 0'7( V t V ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# (� COMPANY NAME E-MAIL FAX STREET ADDRESS f CITY,STATE,ZIP PHONE USE OF %/1 SFD or DUPLEX 0 MULTI-FAMILY PROJECT IN WILDLAND 0 YES PROJECT IN 0 YES IS THE BLDG AN 0 YES IL BUDING: /0 COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE 0 NO EICHLER HOME? 0 NO DESCRIPTION OF WORK ?_—e /,,, p u rel".Le-, t A Gc( --0,.q�..� �s-t�Ne.4y fe,-t- r°e"-1/1„ TOTAL VALUATION: `t' 5 Lj 0 0,9 0 RECEIVED BY:. (I � By my signature below,I ce✓✓✓IfyGtto each of the following: I am the property owner or authorized agent to act on the property own r's beh 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 building construction. I authorize representatives of Cupertino to enter the abovve-identified property for inspection purposes. Signature of Applicant/Agent: (_(J?%__ l� " Date: I /3 // 7 SUPPLEMENTAL INFORMATION REQUIRED w ici USE ONLY D.OVER-TM-COUNTER • • ' ❑ EXPRESS ... IEl STANDARD V z LARGE' , ©, I43AdOR.- MEPMiscApp 2011.doc revised 06/21/11 el 73 D A W tOD V 101f W H T D rt rn . 1 coCM 72 • -, X a -n rt A ..."a O 7 'D fD z -d FL ,, (D n =! y n A N A SO -o 3 '> 3 el -71 ► cro m tn m et) 3 Doi H N 0 -. a D O O N m z o A m 3 n fD 3. 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