B-2018-1148 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:3-2018-1148
10214 PARKWOOD DR APT 8 CUPERTINO,CA 95014-1533(326 27 037) THERMAL
MECHANICAL
SANTA CLARA,CA
95054
OWNER'S NAME:Avery Glenbmok Lp DATE ISSUED;07/13/2018
OWNER'S PHONE: PHONE NO:(408)988-8744
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C4.C10,C20.C36.&038 Lie.#256057
Contractor THERMAL MECHANICAL Dale 0 1/3112 0 2 0 X BLDG X ELECT X PLUMB
I hereby affirm that I am licensed corder 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 full force and effect. JOB DESCRIPTION:
BLDG 60 UNIT#8-(N)AC UNIT;REPLACE FURNACE(SAME
1 hereby affirm under penalty of perjury one of the following two declarations: LOCATION);(N)WASHER/DRYER HOOK-UPS;REPLACE
r. 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(10);REPLACE LIGHT
performance of the work for which this permit is issued, (BATHROOM);(N)(1)EXHAUST FAN(BATHROOM)
I. I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,focthe performance of 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: Overponey'rype:
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 indernolfy 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 com y with all non-point
source regulatio per the Cupertino Mu 1 e,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signatur ate 7_1 Issued by:Kim Dunbar
Date:07/13/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOTS,
following two reasons: All roofs shall be inspected prior to any roofing material being installed.Its roof is
t. 1,as owner of the 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 struchue is not Intended or offered for inspection.
sale(Scc.7044,Business&Professions Code)
1. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to const act the project(Sec.7044,Business&Professions Code), Data L
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
a. 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
z. I have and will maintain Worker's Compensation Insurance,as provided for by I have and the heam elms materials requirements mule,Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Realth&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued. n aintain 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 aHealth&Safety Code,Section 25532(x)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
air contaminadenied mandamus as deed by the Bay Area Air Quality Management Distr' I
Worker's Compensation IaWs of California,If,after making this certificate of will maintain complianeu with the Cupertino Municipal Code,Chapin
exemption,I become subject to the Worker's Compensation provisions of the the Health&Sat'ety Code,5 tions 25505,25533,and 2 -
Labor Code,l must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:7_1
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGNCY
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. I understand my plans shall be used as public records.
Signature Data 7_1 Licensed
Professional