B-2018-1360 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1360
21030 HAZELBROOK DR CUPERTINO,CA 95014-1629(326 55 035) OWNER/BUILDER
OWNER'SNAME:
PHONENOt
LICENSEDDECLARATION BUILDING PERMIT INFO:
License Class Lid.#
Contractor OWNER/BUILDER Date X BLDG—ELECT_PLUMB
I hereby affirm that I am licensed under 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:
REPLACE FURNACE(SAME LOCATION);REPLACE AC UNIT
I hereby offirm under penalty ofperjmy one of the following two declarations: (SAME LOCATION)
t. 1 have and will maintain a certificate of consent to lf-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 I 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:$8000,00
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 stale laws relating to building construction,and hereby authorize 326 55 035
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 8-13-2018 Issued by:Kim Dunbar
Date:08/13/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS'
]allowing two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
r. 1,as owner orthe property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
ampensation,will do the work,and the structure is not intended or offered for inspection.
.to(Sec.7044,Business&Professions Cade)
z. I,as owner of the property,am exclusively contracting with licensed Signature ofApplicanr
contractors to construct the project(Sec.7044,Business&Professions Code). Date:8-13-2018
1 hereby offirm under penalty of perjury one of the following three declarations; ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
t. I have and will maintain a Certificate of Consent to self-insure I'or Worker's
Componsation,as provided for by Section 3700 of the Labor Code,Por 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',ad the hazardous materials requirements undo,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 25534.1 will
permit is issued. maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
J shall not employ any person in any manner so as to become subject to the name ial.Additiounlly,sImedld I use equipment or devices which craft hazardous
u•contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation lows of California.If,ager making this certificate of wBl maintain compliance with the Cupertino nidpal Code,Chapter 9.12 and
exemption,I become subject to die Worker's Compensation provisions of the the Health&Safety Code,Sections 505,25 25534.
Labor Code,I mast forthwith comply with such to or this.permit shall �
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:B-13-2018
Certify that I have read this application and Stale that the above Information ie CONSTRUCTION LF, AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction ncj ng agency for the performance
relating to building construction,and hereby authorize representatives of thle 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 AItCHI'PECT'S DECLARATION
Code,Sectlon .1 I understand my plans shall be used as public records.
Signature Data 8-13-2018 Licensed
Professional