B-2018-1151 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1151
10280 PARKWOOD DR APT 2 CUPERTINO,CA 95014-1512(326 27 036)110280 THERMAL
PARKWOOD DR CUPERTINO,CA 95014-1512(326 27 036) MECHANICAL
SANTA CLARA,CA
95054
OWNER'S NAME:AVERY GLENBROOKLP DATE ISSUED:07/13/2018
OWNER'S PHONE: PHONE NO:(408)988-8744
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C4.010.C20.C38.&C38 Lic.#258057
Contractor THERMAL MECHANICAL Date 01/31/2020 X BLDG X ELECT X PLUMB
I herebyaffirm that I am licensed under the provisions of Chapter 9 X MECH X RESIDENTIAL_COMMERCIAL
p p (commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in tail force and effect. JOB DESCRIPTION:
BLDG 8 UNIT#2-(N)AC UNIT;REPLACE FURNACE(SAME
I hereby affirm under penalty ofperjury one of the following two declarations: LOCATION);(N)WASHER/DRYER HOOK-UPS;REPLACE
L I have and will maintain a certificate of consent to self-insure for Worker's ELECTRICAL PANEL(70 AMP)(SAME LOCATION);(N)GAS LINE
Compensation,as provided for by Section 3700 of the Labor Code,for the FOR STOVE;REPLACE OUTLETS(t0);REPLACE LIGHT
performance of the work for which this permit is issued. (BATHROOM);(N)EXHAUST FAN(BATT-]ROOM)
z. I have and will maintain Worker's Compensation Insurance,as provided£or by
action 3700 of the Labor Code,for the performance o£the work for which this
permit is issued. Sq.Ft Floor Area: Valuation;$20000.00
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 32627 036
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 m I ith all non-point
source regulations per the Cupertino Muni - action 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signatur to 07-13-2018 Issued by:Kim Dunbar
Date:07/13/2018
OWN R-BUILDER DECLAI2A'1%
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All ..is shall be inspected prior to say roofing material being installed.If. of is
m. 1,as owner of rhe property,or my employees with wages as than sole installed without first obtaining an inspection,l 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. 1,as owner of the property,am exclusively contracting with licensed Signature of'Applicant:
contractors to construct the project(See.7044,Business&Professions Code). Date:07-13-2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOK COVERINGS TO BE CLASS"A"OR BETTER
m. 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. HAZARDOUS MATERIALS DISCLOSURE
1. I have and will maintain Worker's Compensation Insurance,as provided to,by 1 have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,Por an
the bertha of the work for which this California Healdm&Safety Code,Sections 25505,25533,.,,it 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 pemrit is issued,I Heahh&Safety Cade,Section 25532(x)should I stu•e or handle hazmdnus
shall not employ in an manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
I y any person y J air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 112 and
.exemption,1 become subject to the Worker's Compensation provisions of the the Health&Safety Co -actions 25505,25533,an I
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized age
APPLICANT CERTIFICATION Date:07-13-2018
I certify that I have read this application and state that the above information Is CON TRUCTION LENDINW6ENCY
.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-polnt source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
SignatureLicensed
Data 07-13-2018
Professional