B-2017-03781
CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0378
1185 ELMSFORD CT CUPERTINO, CA 95014-4907 (362 08 030)
ATKINSON
CLIMATROLLERS INC
i
SAN JOSE, CA 95112
OWNER'S NAME: SLEE ROBERT ROY TRUSTEE & ET AL
DATE ISSUED: 03/07/2017
OWNER'S PHONE: 408-981-1529
PHONE NO: (408) 294-6290
i I
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C=20 Lic. #258540
Contractor ATKINSON CLIMATROLLERS INC Date 12/31/2018
X BLDG _ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
MECH X RESIDENTIAL COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
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license is in full force and effect.
JOB DESCRIPTION:
(1) TANKLES S WATER HEATER - GARAGE
I hereby affirm under penalty of perjury one of the following two declarations:
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
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performance of the work for which this permit is issued.
z�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
Sq. Ft Floor Area:
Valuation: $5210.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this, application and state that the above
I
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
362 08 030
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.
✓ Date 3/7/2017
Issued by: AbbyAyende
-Signature
OWNER -BUILDER DECLARATION
Date: 03/07/2017
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RF. -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
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
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compensation, will do the work, and the structure is not intended or offered for
inspection.
sale (Sec.7044, Business & Professions Code)
z. 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: 3/7/2017
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
z. 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, IHealth
& Safety Code, Section 25532(a) should I store or handle hazardous
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 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.
G
Owne or authorized agent:
Date: 3/7/2017
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 and state laws
CONSTRUCTION LENDING AGENCY
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
be used a
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 3/7/2017
Professional
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GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255
(4081777-3228 - FAX t4081777-3333, building IM- —fl— Rol I Q r_
CUPERTINO b� . �j
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/CONTRACTOR 11 CONTRACTOR AGENT El ARCHITECT El ENGINEER El DEVELOPER El TENANT
CONTRACTOR NAME
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LICENSE TYPE C - ZD
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USE OF FD o, DUPLEX 0 MULTI
BUILDING: rl COMMERCIAL 77-7
PROJECT IN WILDLAND El YES
URBAN INTERFACE AREA ❑ NO
PROJECT IN D YES
FLOOD ZONE 0 NO
IS THE BLDG AN D YES
EICHLER HOW? ❑ NO
DESCRIPTION OF WORK
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TOTAL VALUATION:
RECEIVED BY;
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 behalAl 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 t ilding cons hon. I auth tatives of Cupertino to enter the above -identified property for inspection purposes.
Signature ofApplicant/Ag( Date:
SUPPLEMENTAL INFORMATION REQUIRED
OFFICE USF ONEY
❑ OVER-THE
CI EXPRESS
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MAJOR
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