B-2018-0568 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0568
842 S STELLING RD CUPERTINO,CA 95014-4223(359 20 026) SANDIUM INC
SAN JOSE,CA 95134
OWNER'S NAME: DATE ISSUED:04/09/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class a Lic.#888119
Contractor SANDIUM INC Date 12/31/2018 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 of the Business&Professions Code and that my
license is in]'all force and effect. JOB DESCRIPTION:
REPLACE FURNACE-SAME LOCATION;INSTALL AC-
I hereby affirm under penalty of perjury one of the following two declarations: BACKYARD;RIJN AC ELECTRICAL
z. 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,fmthe
performance 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 Area: Valuation:$10000.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
information is correct.I agree to comply with all city and county ordinances APN Number: occupancy Type:
and state laws relating to building construction,and hereby authorize 359 20 026
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature . / Date 9 9-2101$ Issued by:Kim Dunbar
Date:04/09/2018
OWNER-BUILDER DECLARATION.
I hereby affirm that 1 am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: A11 roofs shall be inspected prior to nay rooting motenel being instal led.If's roof'is
t. 1,as owner of the property,or my employees with wages as their sale installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure Isom intended or offered fm, inspection.
sale(Sec.7044;Business&Professions Code)
z. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec.7044,Business&Professions Cade). Date:4-9-2018
I hereby affirm under penalty of perjury one of the]'allowing three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 1 have and will maintain a Certificate of Conscnt to self-insure For Worker's
Compensation,as provided for by Section 3700 o£the Labor Code,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
i. 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.I will
permit is issued. maintain compliance with the Capin tine Municipal Code,Chapter 9.12 and the
s. 1 certify that in the performance of the work for which this permit is issued,I Health&Safety Codc,Section 25532(.)should I store at-handle hazardous
shall not employ any person in any manner so as to become subject to the materbd.Additionally,should I use equipment or devices which emit hazardous
air contaminants.s degned by the Bay Are.Air Quality Management District 1
Worker's Compensation laws of California.If,after making this certificate of will.,.Intal.compliance with the Cupertino Municipol Code,Chapter 9.12.,,it
exemption,I become subject to the Worker's Compensation provisions of the the He.lth&Safety Codc,SS ons 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall /
be deemed revoked. Owner or authorized agent: /
APPLICANTCERTIFICATION Date: -9-2018
I certify that I have read this application and stale 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 bullding 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, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit.Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHI'TECT'S DECLARA'T'ION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Data 4-9-2018 Professional