B-2018-2182CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2018-2182
19376 STEVENS CREEK BLVD CUPERTINO, CA 95014-2526 (375 01018)
MATRIX HG INC
CONCORD, CA 94520
- ---------- -
OWNER'S NAME:
DATE ISSUED: 01/04/2019
OWNER'S PHONE:
PHONE NO: (925) 459-9200
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C10, B Lic. #812232
Contractor MATRIX HG INC Date 09/30/2020
X BLDG —ELECT —PLUMB
MECH RESIDENTIAL X COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
—
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
BANK OF AMERICA- T.I. - RE -DUCTING; (N) AIR DEVICE; (N) 2
1 hereby affirm under penalty of perjury one of the following two declarations:
TON SPLIT SYSTEM ON SECOND FLOOR
. 1 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.
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: $39248.00
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
375 01 018
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
the
Additionally, th ap icant unoerstemcls and will comply with all non -point
c
source regulations lat ons p r the Cu rt'';01 ivy I ip I Code, Section 9.18.
'
180 DAYS FROM LAST CALLED INSPECTION.
Date: 01/04/2019
OWNER -BUILDER
ON
I hereby affirm that I am'bxempt fr m the Contractor's License Law for one of the
RE -ROOFS:
following two reasons
All roofs shall be inspected prior to any roofing material being installed. If a roof is
1. 1, as owner of the property, 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)
2. 1, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 1/4/19
1 hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 1 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
2. 1 have and will maintain Worker's Compensation Insurance, as provided for by
I have read the hazardous materials requirements under 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 Code, Chapter 9.12 and the
3. 1 certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(a) should I(kore 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 device ich emit hazardous
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined by the Bay Area Air Qu lity a gement District I
�
Owner or authorized agent:
APPLICANT CERTIFICATION
Date: 1/4/19
I certify that I have read this application and state that the above information is
C-QNSTRU-CMN LEND,
correct. I agree to comply with all city and county ordinances and state laws
I hereby affirm that there is a construction lendin ,agency r 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
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
ARCHIT ECI!SFCLARADDN
Code, Section 9.18.
1 understand my plans shall be used as public records.
Signature Date 1/4/19
Licensed
Professional