B-2017-1247CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1247
11701 REGNART CANYON DR CUPERTINO, CA 9501411830 (366 46 001)
ATKINSON
CLIMATROLLERS INC
SAN JOSE, CA 95112
OWNER'S NAME: HOYT SUSAN MARGARET TRUSTEE
DATE ISSUED: 07/28/2017
OWNER'S PHONE: 408-255-5571
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 (ATTIC -SAME LOCATION; INSTALL (M A/C
Thereby affirm under penalty of perjury one of the following two declarations:
BACKYARD
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 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: $13307.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
66
366 46 001
3
arid state laws relating to building construction, and hereby authorize
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.
Additionally, :the applicant understands and will comply with all non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS. FROM LAST CALLED INSPECTION.
re V ` Date 7 2 2 17
Issued by: Jasmine Archbold
Y.,R-BUILDER
Date: 07/28/2017
Thereby 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:
t. 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: 7/28/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
t. 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
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
a. 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
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 25553344.
Labor Code, I must forthwith comply with such provisions or this permit shall
Ql.���
be deemed revoked.
Ow o or authorized a ent: O,I(l`�
g
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
7/22017
or 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, Cli 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
ARCHITECT'S DECLARATION
and will comply with all non -point source regulations per the Cupertino Municipal
I understand my plans shalt be used as public records
Code, Section 9.18.
i
Licensed
Signature Date 7/28/2017
Professional
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 MISC
(408) 777-3228 • FAX (408) 777-3333 • building cDcupertino.orcl
5 zt;, (-1 - I ZLf -.I--
❑ PLUMBING MECHANICAL ELECTRICAL [:]MISCELLANEOUS
PROJECT ADDRESS [1-701 o�,A CAn APN #
OWNER NAV 1 ✓\ PHONE �50 O O `�1I' a r� ` gr pVl Yt 1011Is C I
-77
STREET AD1� SS Y� CI�VAT�r41 �� 5 �y FAX
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CONTACT NAMED ✓ ` / PIi 9 �1 n / E-MAIL �� l �� �' /a �� r•
STREET ADDRESS � {'1 54 ` I CIT Y 's" E . (.0 rG FAX V
❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME VOLee FAX
L- Vq j j � 1 11� LICENSE NUMB$R „ LICENSE TYPE BUS. LIC # ® O
ev
COMPANY NAME � / 111t�`/ I I `Yi _(I E MAIL���" ^ 1 V V Vj I com
STREET ADDRESS �/ j,] T+ CITY, STATEJIL C� C, ME -71 AJ
ARCHITECT/ENGINEER NAME LICENSE NUMBER J BUS. LIC #
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY, STATE, ZIP PHONE
USE 'OF SFD or DUPLEX ❑ MULTI FAMILY PROJECT IN WILDLAND ❑ YES PROJECT IN ❑ YES IS THE BLDG AN ❑ YES
BUILDING: ❑COMMERCIAL URBAN INTERFACE AREA ❑ NO FLOOD ZONE ❑ NO EICHLER HOME? ❑ NO
DESCRIPTION OF WORK �� I u r Yi o I oA i �/A Y to
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MTAIF "t
TOTAL VALUATION: 9c I 0
2'EC1;
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 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 building c nstru ttt I au/th-orie representatives of Cupertino to enter the above -identified property
7for inspection purposes.
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Signature of Applicant/Agent: (� Date:
SUPPLEMENTAL INFORMATION REQUIRED
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MEPMiscApp_201 1. doc revised 06/21/11
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