BLD-2020-1058BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 21361 COLUMBUS AVE Cupertino
APN: 362 04 005
PERMIT NO: BLD-2020-1058
CONTRACTOR:
SANDIUM INC, 4223 VERDIGRIS CIR SAN JOSE
CONTRACTOR PHONE:
4086900289
DATE ISSUED 7/20/2020 4:46:52 PM
ISSUED BY: Sean Hatch
VALUATION: $1 1750
JOB DESCRIPTION
LOCATION); NEW AC UNIT
REPLACE FURNACE (SAME
LICENSED CONTRACTOR DECLARATION
INSULATION AND ACOUSTICAL, B GENERAL BUILDING CONTRACTOR
9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full
CONTRACTOR:
SANDIUM
LICENSED
C20
LICENSED
888119
EXP
12/31/2020
I hereby
force
I hereby
INC
CLASS:
WARM -AIR HEATING%2C VENTILATING
NO:
DATE:
affirm that I am licensed
and effect.
affirm under penatiy of
I have and will maintain a
for which this permit is issued.
I have and will maintain Worker's
I certify that in the performance
laws of California.
with such provisions or this
AND AIR-CONDITIONING, C-2
under the provisions of Chapter
perjury one of the following three
certificate of consent to self -insure
Compensation Insurance,
of the work for which this
If, after making this certificate
permit shall be deemed revoked.
declarations:
for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
work
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's
of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith
V
issued.
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance
I have read the hazardous materials requirements under
the Cupertino Municipal Code, Chapter 9.12 and the Health
V
with
equipment
Municipal
& Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
Sections 25505, 25533, and 25534.
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety Code,
EPA LEAD -SAFE DISCLOSURE
Renovator will be responsible for this project.
Firm Certification No:
Firm is required for this project.
An EPA Lead -Safe Certified
Firm Name:
No EPA Lead -Safe Certified
Certified
v
CONSTRUCTION LENDING AGENCY
lending agency for the performance of the work which this permit is issued (Section 3097, Civil Code).
Lender's Address:
I hereby
Yes
affirm
under penalty of perjury that there is a construction
No
V
Lender's
Name:
APPLICATION CERTIFICATION
and state that the above
representatives of this city
against liabilities, judgements, costs,
will comply with all non -point source
information is correct. I agree to comply with all city and county ordinances and state laws relating to building
to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,
regulations per the Cupertino Municipal Code, Section 9.18.
I certify that I have read
construction, and hereby
harmless the City of
the applicant understands
Signature:
this
authorize
Cupertino
days after its issuance, or if the work authorized on the site by such permit is suspended or abandoned for a period
of 365 days after the time the work is commenced.