11120014 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: I RESULTS WAY CONTRACTOR:XL CONSTRUCTION PERMIT NO: 11120014
OWNER'S NAME: EMBARCADERO CAPITAL PARTNERS 851 BUCKEYE Cr DATE ISSUED: 12/01/2011
R'S PHONE: 4089961010 MILPITAS,CA 95035 PHONE NO:(408)240.6010
111y'? LICENSED CONTRACTOR'S DECLARATION r r r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License.ClessT Lic.N
�� o MEC" r RESIDENTIAL r COMMERCIAL �
Contracmr�b LING+.SIfu(�lOh1 Date I� l �
he eby`atftrfi that I aIle licensed under the provisions o Chupinr 9 30S DESCRIPTION:APPLE.-BLDG 12-SHORING UNDERPINNING FOR ANEW
(enmmencing with Section 7000)of Division 3 of the Business&Professions l,Saq PI'LOIt81'AT❑LDG 12
Code And that my license is in fall force and effect.
hereby affirm under penally of perjury one of the following Mo declarations;
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,ns provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$70000
Section 3700 of the Labor Code,Ibr the performance of the work for which this
permit is issued. „f�
I XY APN Number:35720041.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of(his city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses whi may accr-A ag st said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this p• an dditiona ,tit plicant understands and will comply
with all non-port so regulat is pe t e Cupertino Municipal Code,Section _s /)
9.18. Issued It Dntet� G
Signature Date ^ r
ti r1.
/OWNER-ALDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,And the streture is not intended or offered for sale(Sce.7044, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS'b\"OR BETTER
1 hereby affirm under penalty of perjury one or the following three 11AZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate orConsent to self-insure for Worker's I have read the hazardouamaterials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Ilealth&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued, compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ifeallh&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equi ment or devices which emit hazardous air
contaminants as define . t Bay Area Air Quality Management District 1 will
permit is issued. maintain en Hance 1 th uperlino Municipal Code,Chapter 9.12 and the
I certify that in the performance of Ore work for which this permit is issued,I shall Ilealth y,Cod eti s 25505,25533,and 25534.
not employ any person in my manner so as to become subject to the Worker's
Compensation laws of Califomin. If,after making this certificate of exemption,1 Owauthorize age I
become subject to the Worker's Compensation provisions of the Labor Code,I most Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRl1CTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affrin that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct. I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby Authorize representatives of this city to enter '
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
mg of this permit.Additionally,the applicant understands and Will comply
wa r all 11011-1)0411 Source rcgula klei per the Cupertino Municipid Code,SCCtion I understand my plans shall be used as public records.
9.18.
Licensed Professional_
Signature Date