BLD-2020-1613BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 1 148 SCOTLAND DR Cupertino
APN: 362 28 011
PERMIT NO: BLD-2020-1613
CONTRACTOR: ATKINSON CLIMATROLLERS INC, 1171 NORTH 4TH STREET SAN JOSE
CONTRACTOR PHONE:
DATE ISSUED 10/6/2020 3:01:16 PM
ISSUED BY: JASMINE ARCHBOLD
VALUATION: $5000
JOB DESCRIPTION
REPLACE EXISTING AC UNIT IN BACKYARD
LICENSED CONTRACTOR DECLARATION
-AIR HEATING%2C VENTILATING AND AIR-CONDITIONING, C38 REFRIGERATION, Cl 0 ELECTRICAL
Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full
CONTRACTOR:
LICENSED
C-4 BOILER%2C
LICENSED
EXP
12/31/2020
I hereby
force
I hereby
ATKINSON CLIMATROLLERS INC
CLASS:
HOT WATER HEATING AND STEAM FITTING, C20 WARM
NO: 258540
DATE:
affirm that I am licensed under the provisions of
and effect.
affirm under penatiy of perjury one of the following
I have and will maintain a certificate of consent to
for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,
I certify that in the performance of the work for which
laws of California. If, after making this certificate
with such provisions or this permit shall be deemed
self -insure
this
revoked.
three declarations:
for Worker's Compensation, as provided for by Section 3700 of the Labor Co lie, 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
under
Health
Code,
Chapter 6.95 of the California Health & Safety Code. Sections 25505, 25533. and 25534. I will maintain compliance
I have
the
read the hazardous materials requirements
Cupertino Municipal Code, Chapter 9.12 and the
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
EPA LEAD -SAFE DISCLOSURE
for this project.
Firm Certification No:
project.
An EPA Lead -Safe Certified Renovator will be responsible
Firm Name:
No EPA Lead -Safe Certified Firm is required for this
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
the above
city
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
costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,
source regulations per the Cupertino Municipal Code. Section 9.18.
I certify
construction,
harmless
the applicant
Signature:
that I
the
have read this application and state that
and hereby authorize representatives of this
City of Cupertino against liabilities, judgements,
understands and will comply with all non -point
.