B-2017-1173CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1173
10153 PARKWOOD DR APT 1 CUPERTINO, CA 95014-1456 (326 27 037)
THERMAL
MECHANICAL
SANTA CLARA, CA
95054
OWNER'S NAME: AVERY GLENBROOK LP
DATE ISSUED: 07/25/2017
OWNER'S PHONE: 650-961-8330
PHONE NO: (408) 988-8744
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C-4 10.20.38 Lic. #256057
Contractor THERMAL MECHANICAL Date 01/31/2018
X BLDG X ELECT X 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:
BLDG #35/UNIT#1; ADD (N) A/C; REPLACE FURNACE, SAME
I here affirm under penalty of perjury one of the following two declarations:
LOCATION; (I) WASHER AND DRYER HOOK UPS; (1) ELECTRICAL
r. I have and will maintain a certificate of consent to self -insure for Worker's
SERVICE (70 AMP); (I) GAS LINE FOR STOVE; (1) RECEPTACLE
t� Compensation, as provided for by Section 3700 of the Labor Code, for the
OUTLETS; (N) LIGHT; (1) BATHROOM EXHAUST FANS.
ormance of the work for which this permit is issued.
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: $20000.00
permit is issued.
1 APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
326 27 037
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 ands will comply with all non -point
source regulations per the Cuperti o Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signaturelto 017 7-25-2
Issued by: Kim Dunbar
Date: 07/25/2017
.1,
OWNER -BUILDER DECLARATION
1, 1 .
I hereby affirm that.I ami exemptfrom 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. I, as owner ofthe property, or my employees with wages as their sole
installed without first obtaining an inspection, I agree to remove all new materials for
I
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 I& pfoperty am exclusively contracting with licensed
Signature ofAppflcant:
contractors to cons'ructthe Iprolect (See.7044, Business & Professions Code).
Date: 7-25-2017
I hereby affirm under penaltyof perjury oneof 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 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. %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 Compensahon,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, S 505, 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: 7-25-2017
I certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
correct. I agree to comp] ywith all city'and county ordinances and state laws
I hereby affirm that there is a construction lending agency for the performance
relating to building constructon,'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 imentioned. property for inspection purposes. (We) agree
Lender's Name
to save indemnify and keep harmless'th'e City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in
Lender's Address
consequence of the grantingl 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;
I understand my plans shall be used as public records.
Signature Date 7-25-2017
Licensed
Professional