BLD-2020-1620BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 1061 NOVEMBER DR Cupertino
APN: 362 16 013
PERMIT NO: BLD-2020-1620
OWNER'S NAME: RIDDLE RALPH W JR AND BEVERSTEIN ROXANNE C
OWNER'S PHONE: 4084462155
JOB DESCRIPTION
REPLACE FURNACE AND AC UNIT LIKE FOR LIKE
LICENSED CONTRACTOR DECLARATION
INC
9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full
CONTRACTOR:
LICENSED
C36
LICENSED
EXP
10/31/2021
I hereby
force
I hereby
CLASS:
PLUMBING,
NO: 742039
DATE:
affirm
and effect.
affirm
I have and
for which
I have and
I certify that
with
A R S AMERICAN RESIDENTIAL SERVICES OF CALIFORNIA
C20 WARM -AIR HEATING%2C VENTILATING AND AIR-CONDITIONING
that I am licensed under the provisions of Chapter
under penatiy of perjury one of the following three declarations:
will maintain a certificate of consent to self -insure for Worker's
this permit is issued.
will maintain Worker's Compensation Insurance, as provided
in the performance of the work for which this permit is issued,
laws of California. If, after making this certificate of exemption,
such provisions or this permit shall be deemed revoked.
Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
work
for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
I shall not employ any person in any manner so as to become subject to the Worker's
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
& Safety
as defined
Sections 25505,
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
Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
25533, and 25534.
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety Code,
EPA LEAD -SAFE DISCLOSURE
for this project.
Firm Certification No:
An EPA Lead -Safe Certified Renovator will be responsible
Firm Name:
No EPA Lead -Safe Certified Firm is required for this project.
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
information
to enter upon
costs, and expenses
source regulations
is correct. I agree to comply with all city and county ordinances and state laws relating to building
the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
which may accrue against said City in consequence of the granting of this permit. Additionally,
per the Cupertino Municipal Code, Section 9.18.
I certify that I have read this application and state that the above
construction, and hereby authorize representatives of this city
harmless the City of Cupertino against liabilities, judgements,
the applicant understands and will comply with all non -point
Signature:
L A
.- • 1 III
OF
.