B-2017-0623i
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-0623
22981 STONEBRIDGE ST CUPERTINO, CA 95014-5640 (342 13 017)
PELLE HEATING &
AIR INC
SAN JOSE, CA 95111
OWNER'S NAME: JALBERT CHRISTOPHER P
DATE ISSUED: 04/20/2017
OWNER'S PHONE: 408-892-9423
PHONE NO: (408) 978-7060 i
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class _Q_ -M Lic. #809887
Contractor PELLE HEATING & AIR INC Date 10/31/2017
X BLDG —ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
X MECH X RESIDENTIAL 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 HEAT PUMP -ROOF
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
i
Compensation, as provided for by Section 3700 of the Labor Code, for the
;
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
permit is issued.
Sq. Ft Floor Area:
Valuation: $8000.00 i
APPLICANT ANT RTIFI ATION
1 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
34213 017
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.
Additional)he,applicant understands and will comply with all non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source. q la i e Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Vper
Signature Date 4/20/2017
Issued by: AbbyAvende
OWNER- DER DECLARATION
Date: 04/20/2017
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 .
t. 1, 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 foil
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: 4/20/201
I hereby affirm under penalty of perjury one of the following three declarations:Ai,T
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.
I have Worker's Compensation Insurance, for by
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
z. and will maintain as provided
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 ll
3. 1 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 y Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the u erten Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
, the Health & Safety C e S1 ods 25 5 25533 and 25534.
, ,
Labor Code, I must forthwith comply with such provisions or this permit shall
i
be deemed revoked. ;
"6wner or authorized agent:
APPLICANT CERTIFICATION C�'
Date:/4 20/2017
I certify that I have read this application and state that the above information is
I to laws
CONSTRUCTION I4E19DING AGENCY
I hereby affirm that there is a construction ending agency for the performance
correct. agree comply with all city and county ordinances and state
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 1
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.
1 understand my plans shall be used as public records.
Licensed
Signature Date 4/20/2017
Professional
GENERAL PERMIT APPLICATIONMEF
COMMUNITY DEVELOPMENT. DEPARTMENT • BUILDING DIVISION
}' 1j 10300 TORRE,AVENUE • CUPERTINO, CA 95014-3255 i
CU?ERTI-[ `iU (408) 777-3228 • FAX (408) 777-3333 • buildina(d)cupertino.org i
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PLU 4BING X f MI:( HANIC�AT. X IFT Fr`TATr'ar
PROJECT ADDRESS , 6V,4r
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OWNER NAME &HF-9� �® aJ9,e � PHONE es,_C� V y Z E-MAIL
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❑ OWNER ❑ OWNER -BUILDER ❑ OIXWMAGENT ❑ CONTRACTOR ❑ CONTRACTORAGENTr ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
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LICENSE NUMBER Ff� ll
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TLICENSETYPE C+�
BUS. LIC f C�
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COMPANY NAi
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STREET ADDRESS
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PHONE
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ARC"HITECT/ENGr\BER NAME
LICENSE NUMBER
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E-MAIL
FAX —
STREET ADDRESS
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CITY, STATE, 'LIP
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USE OF SFD orDLTLEX V MULTI-FAMII,Y
BUII.DING: ❑ COMMERCIAL
PROJECT IN WILDLAND ❑ 'ITS PROJECT IN ❑YES
URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO
IS THE BLDG AN ❑ ITS
EICHLER HOME? ❑ NO
DESCRIPTION OF WORK
�, {fir r .t• -a CC?�- °r � �r�� (,w > ��,
TOTAL VALUATION: DO
3_. .
RECEIVED BI � �
By my signature below, I certiyeache following: I am the property owner or authorized agent to act on the property ownerl behalf. have read this
application and the informatios correct. Ih ve'read the Description ofINTork and verify it is accurate. I a� e to co ply with all applicable -local
ordinances and state laws relatconstructio . authorize representatives of Cupertino to enter the above -i en red pro erty for inspection proposes.
Signature of ApplicantlAgent: Date: t7
SUP ME INFORMATION REQUIRED ! 1i
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