B-2018-0885 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMITNO:B-2018-0885
21327 GLEN PLAPT 8 CUPERTINO,CA95014-1471(326 27 036) THERMAL
MECHANICAL
SANTA CLARA,CA
95054
OWNER'S NAME:AVERY GLENBROOKLP DATE ISSUED:05/23/2018
OWNER'S PHONE:650-961-8330 PHONE NO:(468)988.8744
LICENSED CONTRACTOR'S BUILDING PERMIT INFO:
License Class C4.C10,C20.C36.&C38 Lt..#256057
Contractor THERMAL MECHANICAL Dale 01/31/2020 X BLDG X ELECT X PLUMB
I hereby affirm that 1 am licensed tinder the provisions of Chapt'•9(commencing X MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of tlne Brisiness&Professions Code and tlmt my
license is in full force and effect. SOB DESCRIPTION:
BLDG 40 UNIT#8-(N)AC UNIT;REPLACE FURNACE(SAME
I hereby affirm under penalty of perjury one of the following two 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 of the work for which this permit is issued. (BATHROOM);(N)(1)EXHAUST FAN(BATHROOM)
have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 orthe Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$20000.00
APPLICANT CER'TIFICA'TION
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 slate 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 the cu o Municipal code,Section 9.18, 180 DAYS FROM LAST CALLED INSPECTION.
Signature - 05-23-2018 Issued by:Kim Dunbar
Date:05/23/2018
OWNER-RUIf,DER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of theRE ROOFS•
following hvo..'[sons: All root's shall be inspected prior to any roofing material being installed.Its roof is
r, 1,a owner of the property,or my employees with wages as their sole nstalled without first obtaining an inspection,I agree to remove all new materials Far
compensation,will do the work,and the structure is not intended or offered for Inspection.
sale(Sec.7044,Business&Professions Code)
z. 1,as owner ofthapropraty,an,exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec,7044,Business&Professions Code). Date:05-23-2018
1 hereby effirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. I.have and will maintain a Certificate of Consent to self-insure fm Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance ofthe 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 or 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
permit is issued, maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and Bre
s. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should 1 store or handle hazardous
shall not employ any person in any manner so as to become subject to the innterial.Additionally,should I rise equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District 1
Worker's Compensation laws of California.If,eller 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 Cod ecthan,25505,25533,and 25534,
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent'
APPLICANT CERTIFICATION Data:05-23-2018 11
I certify that I have read this application and state that the above information is 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,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 ARCHI'I'ECl"S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
SignatureLicensed
Date 05-23-2018
Professional