B-2018-0603 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0603
10193 PARKWOOD DR CUPERTINO,CA 950t4-1551(326 27 037) THERMAL
MECHANICAL
SANTA CLARA,CA
95054
OWNER'S NAME:AVERY GLENBROOKLP DATE ISSUED:05/07/2018
OWNER'S PHONE:659-961-8330 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 01/3112020 X BLDG ELECT_PLUMB
pr p (com ormu.ag MECH X RESIDENTIAL_COMMERCIAL
1 hereby affirm that 1 am licensed under the provisions of Cha ter 9
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full farce and effect. JOB DESCRIPTION:
BUILDING#51-(N)HOT WATER SYSTEM,100 GAL WATER
I hereby affirm under penalty of perjury one of the following two declarations: HEATER&ENCLOSURE;UPGRADES AND REPAIR OF EXISTING
1. I have and will maintain a certificate of ceusent to self-insure for Worker's BUILDING SERVICES
Compensation,as provided for by Section 3700 of the Labor Code,for the
p £ormance of the work for which this permit is issued,
clave and will maintain WorkePs Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
pen nit is issued. Sq.Ft Floor Ar ea: Valuation:$50000.00
APPLICANTCERTIRICATION
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 WORK IS NOT S'TART'ED
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 05-07-2018 Issued by:Kim Dunbar
Date:05/07/2018
OWNER-BUTLDER DECLARATION
I herehy at'lirm that 1 am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior m any roofing material being installed.Ha roof is
r. t,as owuerof 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 far inspection.
sale(See.7044,Business&Professions Cade)
z. I,as owner of the property,am exclusively contracting with licensed Signature ofApplicmt:
contractors to construct the project(Sec.7044,Business&professions Code). Date:05-07-2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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 forwhich this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. 1 have and will maintain Worker's Compensation lusurance,as provided for by I have read the hazardous mate fats requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the wank for which this Califm ads Hmdth&Safety Cade,Sections 25505,25533,and 25534.I will
permit is issued, maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a I certify that in the performance ofthe work for which this permit is issued,I Health&Safety Cade,Section 25532(a)should I store at'handle hazardous
shall not employ any person in any manner so as to become subject to the rmderial.Additionally,should 1 use equipment or devices which emit hazardous
nir contaminants as defined 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,Clmpter 9.12 and
exemption,1 become subject to the Worker's Compensation provisions of the the Henith&Safety Cade,Sec n 25505,25533,mrd 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:05-07-2018
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 ARCHT'S N'
DECLARATIO
Cade,Section 9.18. 1 understand my plans She
llITEC
be used as public records,
Signature Data 05-07-2018 Licensed
Professional