BLD-2021-0165BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 7803 LILAC CT Cupertino
APN: 359 03 025
PERMIT NO: BLD-2021-0165
OWNER'S NAME: MCHAN MARTIN A AND MARY L TRUSTEE
OWNER'S PHONE: Not Provided
JOB DESCRIPTION
REPLACE FURNACE AND A/C UNIT
LICENSED CONTRACTOR DECLARATION
INCORPORATED
of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full
CONTRACTOR:
LICENSED
C20
LICENSED
EXP
06/30/2021
I hereby
force
I hereby
AIR QUALITY HEATING & AIR CONDITIONING
CLASS:
WARM -AIR HEATING%2C VENTILATING AND AIR-CONDITIONING
NO: 769446
DATE:
affirm that I am licensed under the provisions
and effect.
affirm under penatly of perjury one of the
I have and will maintain a certificate of consent
for which this permit is issued.
I have and will maintain Worker's Compensation
I certify that in the performance of the work
laws of California. If, after making
with such provisions or this permit shall be
following three
to self -insure
Insurance,
for which this
this certificate
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
requirements under
Chapter 9.12 and the Health
Chapter 6.95 of the California Health & Safety Code, Sections 25505. 25533. and 25534. I will maintain compliance
I have read the hazardous materials
the Cupertino Municipal Code,
le
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
will be responsible for this project.
Firm Certification No:
is required for this project.
An EPA Lead -Safe Certified Renovator
Firm Name:
No EPA Lead -Safe Certified Firm
Certified
V
CONSTRUCTION LENDING AGENCY
that there is a construction 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
No
V
Lender's
Name:
APPLICATION CERTIFICATION
and state
liabilities, judgements,
with all
that the above
of this city
non -point
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 that I have read this application
construction, and hereby authorize representatives
harmless the City of Cupertino against
the applicant understands and will comply
Signature:
(Indet..)5?ialpai1111/4".1111111111111111A
.