B-2018-1040 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS; CONTRACTOR: PERMIT NO:B-2018-1040
20020 DE PALMA LN CUPERTINO,CA 95014-3189(369 32 058) SUPREME AIR
SYSTEMS INC
CAMPBELL,CA 95008
OWNER'SNAME:FERTELMEISTER ALEXANDER AND TCHERNOV SUSANN DATE ISSUED:06/19/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C20 Lic.#740667
Contractor SUPREME AIR SYSTEMS INC Date 12/31/2019 X BLDG_ELECT_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 fall force and effect. JOB DESCRIPTION:
REPLACE FURNACE(SAME LOCATION)
I hereby affirm under penalty of perjury one of the following two declarations:
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 Code,for the
performance of the work for which this permit is issued.
�Cwn 1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the per of the work for which this
permit is issued. Sq.Ft Floor Area: Valentino:$1200.00
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 369 32 058
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 hall non-point
source regulations per the Cupertino Municipal Cod ectlon 9.10. 180 DAYS FROM LAST CALLED INSPECTION.
Signature MDate 06119/18 Issued by:Kim Dunbar
Date:06/19/2018
OWNER-BUILDER DECLARATION-
I hereby afflrm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following live reasons: All roofs shall be inspected prior to any roofing material being installed.I£a roof is
r. 1,as owner of the property,or my employee 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 Code)
2. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code), Date:06112/18
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
t. 1 have and will maintain a Certificate of Couscut 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 I have read the hazardous n inentuls requirements order Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Cede,Sections 25505,25533,and 25534.1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is Issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should I use equipment m'devices which craft hazardous
Worker's Compensation laws of California.[f,after making this certificate of air contamlmnts as defined by the Bay Area Air Quality Management District I
P g will maintain compliance with the Cupertino Municipal Code,Chapter9.1 nd
exemption,Ibecome subject to the Worker's Compensation provisions of the the Health&Safety Cade,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:06/19/18
I certify that I have read this application and state that the above information is C NSIR CTION LENDING ACEN
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agenK 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 properly for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses whichmay 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'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 9511911$ Professional