B-2017-1782 •
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1782
20348 CLAY ST CUPERTINO,CA 95014-4403(369 38 030) SUPREME AIR
SYSTEMS INC
CAMPBELL,CA 95008
OWNER'S NAME: MILLER MARTIN H AND CLAUDETTE T TRUSTEE DATE ISSUED: 10/17/2017
OWNER'S PHONE: PHONE NO:(408)376-0406 •
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-20 Lic.#740667
Contractor SUPREME AIR SYSTEMS INC Date 12/31/2017 X BLDG _ELECT _PLUMB
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 10 DUCT SUPPLY
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
performance of the work for which this permit is issued.
/ I have and will maintain Worker's Compensation Insurance,as provided for by •
it) 'Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$3800.00 •
' APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
information is correct.I-a agree to comply with all cityand countyordinances APN Number: Occupancy Type:
9 P Y369 38 030
and state laws'relating to building,'construction,and hereby authorize
j;• representatives of this city to enter upon the above mentioned property for
I; inspectionpurposes. (We)agree to save indemnify and keep harmless the
1 .City of Cupertino against liabilities,judgments,costs,and expenses which. PERMIT EXPIRES IF WORK IS NOT STARTED
1;1 'may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1. Additionally,the applicant understands and will comply with al non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
•
ture Date 10/17/2017 Issued by:AbbyAyende
Date: 10/17/2017
OWNER-BUILDER DECLARATION
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
,.1,1', '1 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
rr, compensation;will do the,work,and the structure is not intended or offered for inspection.
al ; sale(Sec 7044',:Business&Professions Code)
z. I,as owner of the property,ain exclusively contracting with licensed Signature of Applicant:
' Icontractors to construct the project(Sec.7044,Business&Professions Code). Date:10/17/2017
, I hereby'affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I ; 1. :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
' i' performance'of,the work for'which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z.' I have and will maintain Worker's Compensation Insurance,asprovided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700of 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,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
I ' 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:
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,Civ C.)
to enter upon the above mentioned property for inspection,purposes. (We)agree Lender's Name.
to save indemnify and keep harmles§'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. I understand my plans shall be used as public records.
Licensed
Signature Date 10/17/2017
Professional