BLD-2021-1552BUILDING PERMIT
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 20551 SHADY OAK LN Cupertino
APN: 323 44 018
PERMIT NO: BLD-2021-1552
OWNER'S NAME:
CONTRACTOR: ATKINSON CLIMATROLLERS INC DBA VALLEY HEATING,COOLING,ELECTRICAL, 1 171 NORTH 4TH STREET SAN
JOSE
CONTRACTOR PHONE:
DATE ISSUED 9/3/2021 3:45:18 PM
ISSUED BY: phuongd
VALUATION: $4000
JOB DESCRIPTION
FOR LIKE IN CLOSET IN GARAGE
REPLACE FURNACE LIKFE
LICENSED CONTRACTOR DECLARATION
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
12/31/22
I hereby
force
I hereby
ATKINSON CLIMATROLLERS
CLASS:
NO: 258540
DATE:
affirm that I am
and effect.
affirm under penatiy
I have and will maintain
for which this permit
I have and will maintain
I certify that in the
laws of California.
with such provisions
INC DBA VALLEY HEATING,COOLING,ELECTRICAL
licensed under the provisions of Chapter
of perjury one of the following three
a certificate of consent to self -insure
is issued.
Worker's Compensation Insurance,
performance of the work for which this permit
If, after making this certificate
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
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
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 Chapter
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
defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
25505, 25533, and 25534.
or devices which emit hazardous air contaminants as
Code, Chapter 9.12 and the Health & Safety Code, Sections
EPA LEAD -SAFE DISCLOSURE
this project.
Firm Certification No:
An EPA Lead -Safe Certified Renovator will be responsible for
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 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
applicant
the
.
I have read
and hereby
City of Cupertino
understands
this application and state that the above
authorize representatives of this city to
against liabilities, judgements, costs,
and will comply with all non -point source
Every permit issued shall become invalid unless the work on the site authorized by such permit is commenced within 365 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.