B-2018-0644 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0644
10194 PARKWOOD DR CUPERTINO,CA 95014-1547(326 27 037) THERMAL
MECHANICAL -
SANTA CLARA,CA
95054
OWNER'S NAME:AVERY GLENBROOKLP DATE ISSUED:05/07/2018
OWNER'S PHONE:650-961-8330 PHONE NO:(408)988-8744
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class PLUMBING Lie.#256057
Contractor THERMAL MECHANICAL Date 01/31/2020 X BLDG_ELECT_PLUMB
1 hereby affirm that I nm licensed under the provisions ol'Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 Df the Business&Professions Code and Huntley
license is in full force and effect. JOB DESCRIPTION:
BUILDING#55-(N)HOT WATER SYSTEM&ENCLOSURE;
I hereby affirm under penalty of perjury one of the following two declarations: UPGRADES AND REPAIR OF EXISTING BUILDING SERVICES
r. 1 have and will maintain a certificate o£consent to self-insure far Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
0 perFamance of the work For which this permit is issued.
1 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:$50000.00
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 stale 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 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 05-07-2018 Issued by:Kim Dunbar
Date:05/07/2018
01'r
F -R D TI
I hereby affirm that I am exempt Pram the Contractor's License Law for one ot'the RE-ROOFS:
following two reasons: All roofs sholl be inspected prior to any roofing material being installed.If a roof is
t. 1,as owner of the property,o my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compeusatiou,will do the work,sort the suvetote is not intended or offered for inspection.
sale(See.7044,Business&Professions Cade)
z. I,as owner of the property,am exclusively contracting with licensed Signature fApplicant
contractors to construct the project(Sec.7044,Business&Professions Code), Date:05-07-2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS 1'O BE CLASS"A"OR BETTER
t. 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 ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
x 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 porga some,of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.1 will
permit is issued. m aintain cumptlance with the Cupertino Municipal Code,Chapter 9.12 and the
I I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,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 or devices which emit hazardous
1air contamin..is as defined by the Bay Are.Air Quality Management District I
Worker's Compensation laws oIrCtlifnnic.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 Code,Sections 25505,25533,and 25534.
Labor-Code,1 must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agen}:
APPLICANT CERTIFICATION Date:05-07-2018
I certify that I have read this application and state that the above Information is C N'I'R C'I'ION LEND GAGENCY
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 MunicipalARCH1'CEC'P'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 05-07-2018 Licensed
Professional