B-2018-0887 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0887
21316 GLEN PLAPT 11 CUPERTINO,CA(326 27 036) THERMAL
MECHANICAL
SANTA CLARA,CA
95054
OWNER'S NAME:AVERY GLENBROOKLP DATE ISSUED:05/23/2018
OWNER'S PHONE: PHONE NO:(468)988-8744
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C4,C10,C20.C36.&C38 Lic.#256057
Contractor THERMAL MECHANICAL Date 01/31/2020 X BLDG X ELECT X 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&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
BLDG l3 UNIT 411-(N)AC UNIT;REPLACE FURNACE(SAME
1 hereby affirm order penalty orperjury one of the following five declarations: LOCATION);(N)WASHER/DRYER HOOK-UPS; REPLACE
r. I have and will maintain a certificate of consent to self-insure for Worker's ELECTRICAL PANEL(70 AMP)(SAME LOCATION);(N)GAS LINE
Compensation,as provided for by Section 3700 of the Labor Code,for the FOR STOVE;REPLACE OUTLETS(10);REPLACE LIGHT
performance ofthe work for which this permit is issued. (BATHROOM);(N)(1)EXHAUST FAN(BATHROOM)
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,ter the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Voluntion:$20000.00
aFff Aft.CERTIFICATION
I 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 32627 036
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 and will comply with all non-point
source regulations per IF Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature -05-23-2018 Issued by:Kim Dunbar
Date:05/23/2018
OWNER-BUILDER DECLARATION
I hereby at'lirnn that 1 am exempt from the Contractor's License Law for one of the RE-ROOFS:
Following two reasons: All roofs shell be inspected prim to any roofing material being installed.Ifs rout'is
r, I,as owner of the property,or my employees with wages as their sole rrstatled without first obtaining an inspection,l agree to remove all new materials for
ompensotion,will do the work,and the structure is not intended or offered for hrspoction.
sale(Scc.7044,Business&Professions Code)
z 1,as owner of the property,am exclusively contracting with licensed Signature ofApplicrou
contractors to consvuct the project(See 7044,Business&Professions Cade). Date 05-23-2018
1 hereby affirm under penalty of perjury one of the following three decinratimoi: AL1.ROOF COVERINGS TO BE CLASS"A"OR BETTERr. I have and will maintain a Certificate of Consent to,self-insure£or 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 nmteials requirements under Chapter 6,95 at the
Section 3700 of the Labor Code,for the performance of the work far which this Contra I.Health&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued. m aintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I. I ecrtify that in the performance of the work for which this permit is issued,I health&Safety Code,Section 25532(a)should I stare a,-handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should 1 rise equipment or devices which emit le-ardoas
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 complinnce with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cade,Sec 25505,25533,and 25534.
Labor Code,l must forhwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:05-23-2018
I certify that I have read this application and state that the above information is ONSTI =CTION 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,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 ARCHITECT'S DECLARA'T'ION
Code,Section 9.18. 1 understand my plans shall be used as public records.
SignatureLicensed
Data 05-23-2018
Professional