B-2018-0884 CITY OF CUPERTINO BUILDING PERMIT
RUI LDINGADDRESS: CONTRACTOR: PERMIT NO:B-2018-0884
21316 GLEN PL APT 9 CUPERTINO,CA(326 27 036) THERMAL
MECHANICAL
SANTA CLAM,CA
95054
OWNER'S NAME:AVERY GLENBROOK LP DATE ISSUED:05/23/2018
OWNER'S PHONE:650-961-8330 PHONE NO:(408)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 Y PLUMB
I 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 4'rdl force and effect. JOB DESCRIPTION:
BLDG 13 UNIT#9-(N)AC UNIT;REPLACE FURNACE(SAME
I hereby affirm under penalty ofperjury one ofthe following two declaratioron LOCATION);(N)WASHER/DRYER HOOK-UPS; REPLACE
z. I have and will maintain a certificate of cousent to self-insure for Worker's ELECTRICAL PANEL(70 AMP)(SAME LOCATION);IN)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)
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
s
permit is issued. Sq.Ft Floor Area: Valuation:$20000.00
APPLICANT 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 326 27 036
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 Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 05-23-.2018 Issued by:Kim Dunbar
Date:05/23/2018
OWNER-B ILDER DECLARATI
I hereby affirm that I am exempt from the Contractor's License Law for one ofthe BE-
following two reasons: All root's shall be inspected prior to any roofing material being installed.If. of is
r. I,as owner ofthe property,m 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(Scc.7044,Business&Professions Code)
z I,as owner ofthe property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(See.7044,Business&Professions Code). Date:05-23-2018
1 hereby affirm under penalty of perjury one at the following three declarations: ALL ROOF COVERINGS 7'O BE CLASS"A"OR BETTER
1. 1 have and will maintain a Certificate of Consent to self-insure for Workor'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
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
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. I certify that in the performance ofthe work for which this permit is issued,] Health&Safety Cade,Section 25532(a)should I store or handle hozardous
shall not employ any person in any mnn
aer so as to become subject to the nutteri if Additionally,should I use equipment or devices which emit hazardous
air eonhtmirmnts as dctined 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,Se 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 Date:05-23-2018
I certify that I have read this application and state that the above information is CONTRUC'CION'LENDING AGENC
SY
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 A1tCHl'I'F.CT'S DF,CLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
SignatureLicensed
Date 05-23-2018
Professional