B-2018-0882 CITY OF CUPERTINO BUILDING PERMIT
RU ILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2018,0882
10285 PARKWOOD DR APT 4 CUPERTINO,CA(326 27 036) THERMAL
MECHANICAL
SANTA CLARA,CA
95054
OWNER'S NAME:AVERY GLENBROOK LP DATE ISSUED:05/23/2018
OWNER'S PHONE:650-961-8330 PHONE NO:(4b8)989-8744
LICENSED C DECLARATION BUILDING PERMIT INFO:
License Class C4,C10,C20.C36.&C38 Lic.#256057
Contractor THERMAL MECHANICAL Dale 01/3112020 X BLDG X ELECT X PLUMB
I hereby affirm that Lam 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 9 UNIT 94-(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
1. I have and will maintain a certificate of consent to self-insure for Worker's ELECTRICAL PANEL(70 AMP)(SAME LOCATION);(N)GAS LINE
Cars enation,as provided for by Section 3700 of the Labor Code,For the FOR STOVE;REPLACE OUTLETS(10);REPLACE LIGHT
Parfet mance 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
permit is issued. Sq.Ft Floor Arca: Valuation:$20000.00
APPLICANT CERTIFICATION
I certify that I have read this application and stale 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 the Zupo�mniclpal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature at�gE-23-2D18 Issued by:Kim Dunbar
Data:05/23/2018
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law 1'or one of theRE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. 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 structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Cade)
z. 1,as owner of the property,am exclusively contracting with licensed Signature ofApplicane
contractors to construct the project(See.7044,Business&Professions Code). Date:05-23-2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOK COVERINGS TO BE CLASS"A"OR BETTER1. I have and will malr oin a Certificate of Consent to self-insure for 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 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Cade,Sections 25505,25533,and 25534.1 will
permit is issued, maintain comptiance with tine Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance o£nhe work for which this permit is issued,l Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
shall not employ any person in any manner so as to become subject to the material. aza
Additionally,should I use equipment or devices which emit hrdous
err contaminants as defined by the Bay At an 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 Co ro 25505,25531,and 25534.
Labor Code,l 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 CONST ACTION LENDING AGh,NCY
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 Al2CHITECT'S nECLA RATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Data 05-23-2018 professional