B-2018-0651 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018.0651
10183 PARKWOOD DR CUPERTINO,CA 95014-1461(326 27 037) THERMAL
MECHANICAL
SANTA CLARA,CA
95054
OWNER'S NAME:AVERY GLENBROOK LP DATE ISSUED:05/07/2018
OWNER'S PHONE:650-961-8330 PHONE NO:(408)989.8744
LICENSED CONTRAC'TOR'S DECLARATION BUILDING PERMIT INFO:
License Class C4.CIO,C20 C36&C38 Lic.#256057
Contractor THERMAL MECHANICAL Dale O1/31/2020 X BLDG ELECT PLUMB
I hereby affirm that I am licensed ander the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 ofthe Business&Professions Code and that my
Bcense is in fill force and effect. JOB DESCRIPTION:
BUILDING 452-(N)HOT WATER SYSTEM&ENCLOSURE;
I hereby affirm under penalty of perjury one ofthe following two declarations: UPGRADES AND REPAIR OF EXISTING BUILDING SERVICES
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.
haveand will maintain Worker's Compensation Insurance,as provided for by
Sectioit 3700 ofthe Labor Code,for the performance of the work for which this
permit is issued, Sq.Ft Floor Arca: Valuation:$50000.00
APPLICANT CF,RT1fICA'1'ION
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 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
OWNER BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one ofthe RI's-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing matet ia!being installed.To roof is
n. I,as owner ofthe property,or my employees with wages as their sole installed without first obtaining an inspection,l agree to remove all new materials for
compensate.,will do the work,xad the sUa.hoc is not intended or offered for inspection.
auto(Sce.7044,Business&Professions Code)
z. 1,as owner ofthe properly,am exclusively contracting with licensed Signature ol'ApplicanC
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: ALLROOF COVERINGS TO BE CLASS"A"OR BETTER
I, I have and will malutain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 ofthe Labor Code,for the
performance ofdre work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
e. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the h ani dans materials requirements order Chapter 6,95 of the
Section 3700 ofthe Labor Code,for the perfomauce of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.f will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 sad the
3. 1 certify that in the performance ofthe work for which this permit is issued,I Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
shall not employ any person in any manner so as to beenme subject to the material.Additionally,should 1 use equipment or devices which emit hazardous
rc
mntanninants as defined by the Bay Arca Air Quality Management District 1
Worker's Compensation laws of Califmniu.Taber making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter9.12 and
exemption,1 become subject to the Worker's Compensation provisions of the the Health&Safety Code=; and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Data: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-polm source regulations per the Cupertino Municipal ARCHI9'ECT'S DECLARA'T'ION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 05-07-2018 Professional