B-2018-1331 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:13-2018-1331
20655 NANCY CT CUPER1'INO,CA 95014-2913(359 15 027) RESIDENTIAL,
HEATING AND AIR
CONDITIONING INC
CAMPBELL,CA 95008
OWNER'S NAME: DATE ISSUED:08/08/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B C20 Lic.4705554
Contractor RESIDENTIAL HEATING AND AIR CONDITIONING INC Date X BLDG_ELECT_PLUMB
04/30/2019 X MECH X RESIDENTIAL_COMMERCIAL
I hereby affirm that I am licensed corder the provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my JOB DESCRIPTION:
license is In full fractured effect. INSTALL MINI SPLIT SYSTEM(2)-DUCTLESS(7 INTERIOR UNITS)
I hereby affirm under penalty of perjury one of the following two declarations:
r. I have and will maintain a certificate of consent to self-iusme for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance oftehwork for which this permit is issued.
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 Sq.Pt Floor Area: Valuation;$42000.00
permit is issued,
APPLICANT CER'T'IFICATION
I certify that I have read this application and state that the above APN Number: Occupancy Type:
Information is correct.I agree to comply with all city and county ordinances 359 15 027
and state laws relating to building construction,and hereby authorize
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save Indemnify and keep harmless the PERMIT EXPIRES IF WORK IS NOT STARTED
City of Cupertino agalnst liabilities,judgments,costs,and expenses which WITHIN 180 DAYS OF PERMIT ISSUANCE OR
may accrue against said City in consequence of the granting of this permit.
Additionally,the applicant understands and will comply with all non-point 180 DAYS FROM LAST CALLED INSPECTION.
source regulations per the Cupertino Munlcipal Code,Section 9.18.
Issued by:Kim Dunbar
Signature Dale 08-08-2018 Date:08/08/2018
OWNER-BUILDER DECLARATION RGROOII
I hcreby'aftirnr that I am exempt from the Contractor's License Law for one of the All roofs shall be inspected prior to any roofing material being installed.If e clefts
following two reasons; installed without first obtaining an inspection,I agree to remove all new materials for
r. 11
as owner of the property,or my employees with wages as their sole inspection.
empensation,will do the work,and the structure is not intended or offered for
sale(Sec.7044,Business&Professions Code) Signature ofApplicaut _
i. 1,as owner of the property,am exclusively contracting with licensed Date:08-08-2018 '
contractors to construct the project(See.7044,Business&Professions Cede).
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. I have and will maintain a Certiricate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the HAZARDOUS MATERIALS DISCLOSURE
Pat formance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by Calif ornin Health&Safety Code,Sections 25505,25533,and 25534.1 will
Section 3700 of the Labor Code,foot the Exafarmanee of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9,12 and the
permit is issued. Health&Safety Code,Section 25532(a)should I store or handle hazardous
a. I certify that in the performance of the work for which this permit is issued,I material.Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in anymanner so as to become subject to the r contaminants as defhted by the Bay Area Air Quality Management District f
will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
Worker's Compensation laws of California.If,after making this certificate of the Health&Safety Code,Sections 25505,25533,and 25534,
exemption,I become subject to the Worker's Compensation provisions of the
Labor Code,1 must forthwith comply with such provisions or this permit shall
Owner 8-authorized agent:��
be deemed revoked. Date:r or authorized
APPLICANT CERTIFICATION CONSTRUCTION LENllING 'G� CY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance
correct.I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued(Sec.3097,Civ C.)
relating to building construction,and hereby authorize representatives of this city Lender's Name
to enter upon the above mentioned property for Inspection purposes. (We)agree
to save Indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address
judgments,costs,and expenses whichmay accrue against said City in
consequence of the granting of this permit.Additionally,the applicant understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18,
LI lensed -
Professional
Signature Date OB-08-2018