B-2018-0867 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0867
1121 ROLLINGDELL CT CUPERTINO,CA 95014-5809(359 34 009) THERMA TECH INC
SAN JOSE,CA 95125
OWNER'S NAME: DATE ISSUED:05/21/2018
OWNER'S PRONE: PHONE NO:(408)629-5400
LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CC=20 Lic.4913800
Contractor THERMA TECH INC Date 04/30/2020 X BLDG—ELECT_PLUMB
I hereby affirm that I am licensed ander the provisions of Chapter 9(commencing X MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 a]the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE FURNACE-SAME LOCATION
I hereby affirm ander penalty of perjury one of the following two declarations: INSTALL(N)A/C UNIT-SIDE YARD
r. 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 Cade,for the
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 ofthe Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$12000.00
APPLICANT CERTIFICATION
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 359 34 009
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 5/21/2018 Issued by:Jasmine Archbold
Date:05/21/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
rollmving two reasons: All roofs shall be inspected prior to any roofing material being installed,If a roof is
r. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,1 agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered far inspection.
sale(Sec.7044,Business&Professions Code)
x. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to cunstact the project(Sce.7044,Business&Professions Code), Date:5/21/2018
I hereby affirm under penalty of perjury one.1 the following three deal aratfons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTERr. 1 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. 1 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 25534.1 will
permit is issued maintain compliance with the Cupertino Municipal Codc,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Cade,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should 1 use equipment o-devices which emit hazardous
ontaaunts as defined by the Bay Area At,-Quality Management District 1
Worker's Compensation laws of California.If,after making this certificate of wmill maintain cumplia—with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I became subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 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 GC 1"FICATION Date:5/2112,1 8
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 ARCHITECT'SDECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date 52IL20J 8 professional