B-2018-1039 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1039
7512 LEEDS AVE CUPERTINO,CA 95014-5219(366 16 022) SANDIUM INC
SAN JOSE,CA 95134
OWNER'S NAME: DATE ISSUED:06/19/2018
OWNER'S PHONE: PHONE NO:(
LICENSEDTR TOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-20 Lie.!1888119
Contractor SANDIUM INC Date 12/31/2018 X BLDG_ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter9(commencing X MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect JOB DESCRIPTION:
RELOCATE(N)FURNACE-ATTIC;(N)AC UNIT-REAR YARD;
I hereby affirm under penalty of perjury one of the following live declarations: NEW DUCTS;RUN GAS LINE METER TO FURNACE
r. I have and will maintain a certificate Of consent to sal&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.
z. 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:$16000.00
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 366 16 022
representatives of this city to enter upon the above mentioned property for
inspection purposes.C%ul ee to save Indemnify and keep harmless the
City of Cup,;' nst liabilities, d�ments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may acc�.0 against said City In conseq once of the granting of this permit WITHIN 180 DAYS OF PERMIT ISSUANCE OR
�Addl6•nally,the applicant undersla ds nd-will-c mply with all non-ointe
Dale 06/19/2018 Issued by:Jasmine Archbold
Data:06/19/2018
OWNER-BUIL RDECLAI2ATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
Following two reasons: All rool',s shall be inspected prior to any rooting material being installed.Ile root'is
1. 1,as owner of the property,o my employees with wages as their sole ustalled without first obtaining an inspection,1 agree to remove all new materials for
compensation,will do the work,and the struotine is not intended or offered for mspcction.
sale(Scc.7044,Business&Professions Code)
z. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sea7044,Business&Professions Code). Date:06/19/2018
1 hereby affirm mrder penalty of perjury one of the fallowing three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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,for the
performance of die work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous maim mils requirements ander Chapter 6.95 of the
Section 3700 of the Labor Code,for[he 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 Cupertino Municipal Code,Chapter 9.12 and the
Health&Safety Code,Section 25532 ).shonld-I•star r handle hazardous
a. f certify that in the performance of the work for which this permit is issued,1 material.Additional!,slmnld 1 s [ dev' s t hazardous
shall not employ any person in any manner so as to become subject to the y qmp°ren
air contaminants as define.�fire Bay Area Air m icy Ma agement rat 1
Worker's Compensation laws of California.If,after making this certificate of will maintain camplta [h the Cupertino 1n�r: aq,Chapter 9.12 d
exemption,l become subject to the Worker's Compensation provisions of the the Health n Safety Cade,Sections 2 SU5 n533,/and 25534.
Labor Code,l must forthwith comply with such provisions or this permit shall _
be deemed revoked Owner or not hat
APPLICANT CERTIFICATION Date:06/19/2018
1 certify that I have read this application and state that the above information is C
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 properly for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,casts,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 ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Data 06/19/2018 Professional