B-2018-0911 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMIT NO:3-2018-0911
10480 FLORA VISTA AVE CUPERTINO,CA 95(14-1606(326 28 081) PELLE HEATING&
AIR INC
SAN JOSE,CA 95111
OWNER'S NAME: DATE ISSUED:05/29/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Cfl Lia#809887
Contractor PELLE HEATING&AIR INC Date 10/31/2019 X BLDG_ELECT_PLUMB
1 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&Prot'essions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE EXISTING AC UNIT-(MOVE ABOUT 2FT)
1 hereby affirm under penalty of perjury one of the following two declarations:
r. I have and will maintain a certificate of consent to self-instue for Worker's
-` Compensation,as provided for by Section 3700 of the Labor Code,for the
have and will maintain Worker's Compensation Insnreace,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
.permit is issued, Sq.Ft Fluor Area: Valuation:$4772.00
APPLICANT CERTIFICATION
I certify that I have read this application and slate 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 326 28 081
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 Ijd6 Itles,ju�gn ents,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said Ity cone chance of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the ap head un Land and will comply with all non-point
source regulations Municipal Code,Section 9.1 B. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 05-29-2018 Issued by:Kim Dunbar
Date:05/29/2018
OWNER-BUILDER ..,A RAIL/
I hereby affirm that I aro exempt from the Contractor's License Law for one of tire RE-ROOFS,
following two reasons: All roefs shall be Inspected prior to any roofing material being installed.If..of is
r. 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 for
compensation,will do the work,and the atrncton,is not intended or offered far inspection.
sale(S-7044,Business&Professions Code)
r. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(See,7044,Business&Professions Code). Date:05-29-2018
1 hereby affirm under[)easily of perjury one of the following throe declarations: ALL ROOF COVERINGS TO BE CLASS"A"012 BETTER
r. 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 Wei ker',s Compensation Insurance,as provided for by I[lave lead the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for tine performance of the work for which this California Health&Safety Cade,Sections 25505,25533,and 25534.1 will
[)enolt is issued. m iauee afntain ema with thno
e Cape.if..Municipal Code,Chapter 9.12 d the
Health&Safety Code,Section 25532(x)should I store or handle hazardous
s. 1 certify that in the performance offer work for which this penult is issued,I material.Additional),should I use e I
shall nut employ any person fn any manner so as to become subject to the Y qu pmen}�zr device which emit District I
air contaminants ns defined by the llyArea i,'. ohly lanagement Uistrirt 1
Worker's Compensation laws of California.It,after making this certificate of' will maintain complinmce with the
Owner or authorized agent:
APPLICANT CER'T'IFICATION Date:05-29-2018
I certify that I have read this application and state that the above information is CONSTRUCT ON LE DLG 5CYNCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending gency for the performance
relating to building construction,and hereby authorize representatives of this city ofwork'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 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 ARCllfl'L+C'1"S DECLARA'f1ON
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 05-29-2018 Licensed
Professional