10100088CITY OF CUPERTINO BUILDING P RMIT
BUILDING ADDRESS: 20563 STEVENS CREEK BLVD
CONTRACTOR: MATTX HG, INC.
PERMIT NO: 10100088
OWNER'S NAME:
CONCORD, CA 94518
PHONE NO: (925) 459-9200
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: 14ESIDENTIAL COMMERCIAL
License Class, 420, cto Lic. # �( v� 3 a
HVAC RETROFI-t - REMOVE BUILT UP SYSTEM &
REPLACE
Contractor _?T2 tx fflr�C. Date
WITH FIVE (5) NEW ROOF TOP UNITS-ADDITIONAL
1 hereby affirm that I am licensed under the provisions of Chapter 9
WEIGHT
(commencing with Section 7000) of Division 3 of the Business & Professions
STRUCTURAL CALCS
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
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
Sq. Ft Floor Area:
Valuation: $220000
performance of the work for which this permit is issued.
1 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.
APN Number: 32634044.00
Occupancy Type:
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
PERMIT EXI�IRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
building
WITHIN 180! DAYS OF PERMIT ISSUANCE OR
to construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code, Section
9.18.
!G _ �p
Signature ��— Date /
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
Signature of Applicant:_ Date:
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
1 hereby affirm under penalty of perjury one of the following three
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's
Health & Safety Code, Section 25532(a) should I store or handle hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent:
permit is issued.
I certify that in the performance of the work for which this permit is issued, 1 shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
APPLICANT CERTIFICATION
1 certify that 1 have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances 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 City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date