B-2017-0617CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0617
1188 ELMSFORD DR CUPERTINO, CA 95014-4950 (36109 005)
ABC COOLING &
HEATING SERVICES
INC
HAYWARD, CA 94545
OWNER'S NAME: LELLMAN DELIA AND PHILIP E TRUSTEE
DATE ISSUED: 04/19/2017
OWNER'S PHONE: 408-255-3093
PHONE NO: (559) 292-9240
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class S2Q Lie. #382383
Contractor ABC COOLING & HEATING SERVICES INC Date 05/31/2017
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:
DUCT, WORK REPLACEMENTS
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.
C
v2: 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: $4019.00
permit is issued.
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
362 09 005
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 Date 4/1912.017
Issued by: Abby Ayende
Date: 04/19/2017
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's' License Law for one of the
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
r. 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: 4/19/2017
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 ofthe 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
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
a. I certify that in the performance of the work for which this 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 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:
APPLICANT CERTIFICATION
Date: 4/19/2017
1 certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
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
and will comply with all non-point source regulations per the Cupertino Municipal
a DECLARATION
ARC be used
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 4/19/2017
Professional
GENERAL PERMIT APPLICATION E P
COMMUNITY DEVELOPMENT. DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
Ar
ftfi I R I
CUPEF�'�-INO Q
❑ PLUMBING U MECHANICAL ❑ ELECTRICAL 7 MISCELLANEOUS
(408) 777-3228 •FAX (408) 777-3333 • buildino(a�cupertino.ar
PROJECT ADDRESS
APN n E )q ®1`I®
OWNER NAME �� V lY Yt b �✓) PII y fi% C& 3_!,-.� E-MAIL
/o
STREET ADDRESS p
' SS / � FAX
�
CONTACT NAME J r
HONE fJ 5-7,r 2 to
L / v L
E-MAIL
STREET ADDRESS % Q
�C
C STATE, ZIP
FAX
❑ OWNER ❑ OWNIER-BUILDER ❑ OWNERRAAGENT ❑ CONTRACTO'R� ❑ CONTRACTORAGENT ❑. ARCHTTECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME � �
LICEIISI�br � p �
LICEN l
BUS. LIC # 2 q W
COIAPANY NATE
FAX
STREET ADDRESS
3
CITY, A .ZIP
ARCHITECT/ENGLNEER NAME
LICE I -SE NUMBER
BUS. LIC r
COMPAI,TY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, 'LIP
PHONE
USE OF 0SFD yr DUPLEX ❑ MULTI -FAMILY
BUILDING: ❑ COMMERCIAL
PROJECT IN W;tLAND ❑ -YES PROJECT IN ❑ YES
URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ ITS
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
TOTAL VALUATION: / RECEIVED BY
By my signature below, I ertify to ach 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 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 ding constructs I authorize representatives of Cupertino to enter the a1,Iov -A entified rope for inspection proposes.
Signature of Applicant/Agent: Date: (�
SUPPLEMENTAL', INFORMATION REQUIRED
OFFICE vss RNLI
�
=�❑ O) ER THE COUATER - :.
❑ EJO'RESS
<
�. LARGE
❑-A1AJOR --
MEPAdiscApp_201 Ldoc remised 06/21/11