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B-2019-1153 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-1153 20073 NORTHCREST SQ CUPERTINO,CA 95014-0509(316 38 072) ATKINSON CLIMATROLLERS INC SAN JOSE,CA 95112 OWNER'S NAME: DATE ISSUED:06/27/2019 OWNER'S PHONE: PHONE NO:(408)294-6290 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class C20 Lic.#253540 Contractor ATKINSON CLIMATROLLERS INC Date 12/31/2020 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: I hereby affirm under penalty of perjury one of the following two declarations: REPLACE FURNACE SAME LOCATION;INSTALL(N)A/C UNIT- BACKYARD 1. 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. "' 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:$11171.00 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 Number: Occupancy Type: 316 and state laws relating to building construction,and hereby authorize 316 38 072 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. WITHIN180 DAYS OF PERMIT ISSUANCE Additionally,the applicant understands 7/2019 Issued by.Jasmine Archbold Date:06/27/2019 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from 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. I,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 structure is not intended or offered for inspection. sale(Sec.7044,Business&Professions Code) 2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:06/27/2019 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1. 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 2. I 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. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 3. 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 material. Additionally,should I use equipment or devices which emit hazardous shall not employ any person in any manner so as to become subject to the air contaminants as defined b the Ba Area Air ' y y Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the � APPLICANT CERTIFICATION Date:06/27/2019 1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY 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. 1 understand my plans shall be used as public records. Licensed Signature Date 06/27/2019 Professional