B-2018-1046 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1046
22330 HOMESTEAD RD APT 221 CUPERTINO,CA 95014-0137(326 59 046) CAL-STATE HVAC
HILLSBOROUGH,CA
94010
OWNER'S NAME: DATE ISSUED:06/20/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C_20 Lie.#965710
Contractor CAL-STATE HVAC Date 09/30/2019 X BLDG—ELECT—PLUMB
1 hereby nflirm that I am licensed under the provisions of Chapter 9(commencing X MECH X RESIDENTIAL COMMERCIAL
with Section 7000)of Division 3 ofthe Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE CONDENSER HEAT PUMP-SAME LOCATION
1 hereby affirm under penalty of perjury one of the following two declarations:
r. I have and will maintain a certificate of consent to self-insure for Worker's
Compe
� motion,as provided for by Section 3700 of the Labor Code,for the
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the pot Formance of the work for which this
Permit is issued. Sq.Ft Floor Area: Valuation:$5000.00
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 326 59 046
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 WORT{IS NOT STARTED
may accrue against said Ch consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the ap(icanl un islands and will comply with all non-point
source regulations er the pertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature - Date 06/20/2018 Issued by:Jasmine Archbold
Date:06/20/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I ane exempt from the Contractor's License Law for one of theRE ROOFS:
asn
following two rens: All roofs shall be inspected prior to any roofing material being installed.If a roof is
a. I,as owner ofthe 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 for inspection.
sale(Sec.7044,Business&Professions Code)
z. I,as owner ofthe property,am exclusively contracting with licensed Signature ofApplicane
conhuclors to construct the project(See.7044,Business&Professions Cade). Date:06/20/2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 ofthe Labor Code,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous matelals requirements under Chapter 6.95 ofthe
Section 3700 ofthe Labor Code,for the performance ofthe 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
a. I certify that in the performance of the 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 canner so as to become subject to the matecorial.Additionally,should 1 use equipment or devices which emit hazardous
Worker's Compensation Taws of California.If,after making this cetificate of air ntaminants as defined by the Bay Arca Air Quality Management District 1
MH maintain compliance with the Cupertino telcipa ode,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Iledth&Safety Code,Sections 505,2 33,and 255
Labor Code,I must forthwith comply with such provisions a this permit shall
be deemed revoked, Owner or authorized agent: <.
APPLICANT CERTIFICATION Date:06/20/2018
I certify that I have read this application and state that the above Information Is CONSTRUCTION
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 ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 06120/2018 Professional