BLD-2021-0468BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 10413 MERRIMAN RD APT B CUPERTINO
APN: 342 29 029
PERMIT NO: BLD-2021-0468
OWNER'S NAME: FISHER KATHLEEN P
OWNER'S PHONE: 8315883479
JOB DESCRIPTION
-SPLIT SYSTEM (INCLUDES (1) OUTDOOR CONDENSER AND (3) INDOOR AIR HANDLERS)
DUPLEX - UNITS (A) AND (B); ADD (N) DUCTLESS MULTI -ZONE MINI
LICENSED CONTRACTOR DECLARATION
HEATING%2C VENTILATING AND AIR-CONDITIONING, C38 REFRIGERATION, C1 0 ELECTRICAL
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
12/31/2022
I hereby
force
I hereby
CLASS:
NO: 258540
DATE:
affirm
and effect.
affirm
I have and
for which
I have and
I certify that
with
ATKINSON CLIMATROLLERS INC
HOT WATER HEATING AND STEAM FITTING, C20 WARM -AIR
that I am licensed under the provisions of Chapter
under penatiy of perjury one of the following three
will maintain a certificate of consent to self -insure
this permit is issued.
will maintain Worker's Compensation Insurance,
in the performance of the work for which this
laws of California. If, after making this certificate
such provisions or this 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
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
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Lender's
Name:
APPLICATION CERTIFICATION
information is correct. I agree to comply with all city and county ordinances and state laws relating to building
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
construction,
harmless
the
Signature:
that I
the
applicant
have read this application and state that the above
and hereby authorize representatives of this city to
City of Cupertino against liabilities, judgements, costs,
understands and will comply with all non -point source
DI--NlYe
.