B-2018-0883 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: CONTRACTOR: PERMITNO:B-2018-0883
10175 PARKWOOD DR APT 8 CUPERTINO,CA 95014-1460(326 27 037) THERMAL
MECHANICAL
SANTA CLARA,CA
95054
OWNER'S NAME:AVERYOLENBROOKLP DATE ISSUED;05/23/2018
OWNER'S PHONE: PHONE NO:(408)988-9744
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C4.C10.C20.C36.&C38 U..#25605
Contractor THERMAL MECHANICAL Date 01/31/2020 X BLDG X ELECT X PLUMB
I herebyaffirm that I am licensed under the s of Cha ter 9 X MECH X RESIDENTIAL_COMMERCIAL
a provision p (commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is In full force and effect. JOB DESCRIPTION:
BLDG 33 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
t. I have and willlmaintain a certificate of consent to self-insure£mr 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
1 have and will maintain Worker's Compensation lusurance,as provided for by
cation 3700 of the Labor Code,for the performance of the work for which this
P
is issued. Sq.Ft Flom 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 27 037
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 WORT{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 upertino 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-BIIH.DE.R DECLARATION
I hereby affirm that I ant exempt from the Contractor's License Law for one of the RE-ROOFS:
following five reasons: All roofs shall be iuspected prior to any roofing material being installed.If a.of is
t. 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 ren
compensation,will do the work,and the structure is not intended or offered for Inspection.
sale(Sce.7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sce.7044,Business&Professions Cade). Date:05-23-2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTERa. 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 Worker's Compensation Insurance,as provided for by 1 have read the hazardous...fmdals requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the pert'orusn—of the work for which this California health&Safety Code,Sections 25505,25533,and 25534.twill
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. I certify that in the performance of the work for which this permit is issued,l Health&Safety Code,Section 25532(.)should 1 store or handle hnz.rdin s
shall not employ any person in any manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California,If,afler making this eertificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions ofthe the Health&Safety Code,Sections 25505,25533,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:05-23-2016
I certify that I have read this application and state that the above Information Is CONSTRU/TION 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-paint source regulations per the Cupertino Municipal AIiCHI'1'ECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 05-23-2018 Licensed
Professional