12050102 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20380 S EVENS CRITK BLVD CONI"RMA OR: WAI'I[R I IIIA IIERS ONLY PF-RNII"1NO: 120MI02
O\VNF,R'S NAME: CU1117RI[NO CI'T'Y CEN'I'17R APARTMENTS II 9701.NIAIN S " DA I E ISSI:11D:US/l0/2012
OWNER'S 1'IIONE: 4082537100 GRASS VALLE\'.(:A 95945 P11US(:NO:I8001a35-5946
â I,1('EN:SEI)CON"IR:\C."fOR'S DF,CI,AR:VI'ION r I Fâ
BUILDINGI'k:R,\I I'f INFO: BLDG ELECT PLUMBLicense Claus Lic.u r F F
NIECII RESIDENTIAL COMMERCIAL
Cunlractnr Date
I herehy affirm that I am licensed under Elie provisions of Chapter') JOB DESCRIPTION: Rlil'I,AC'h.S0G N':\fliK Ilinll(K IN AI':Vt'I NII:ST
(nntmhctcing with Section 711111)of Division 3 of the Business.Y Professions CONIPI.FN
Code and that nn'license is in tail force and effect.
hereto affirm under penally ul"perjury one of the following Iwo declarations:
I have and will maintain it cenificme of consent to sell"-insure for W'orker's
Compensation.as provided for by Section 3700 of the Labor Code,for the
perlbrnhnnce ol'the work for which this permit is issued.
I have and +'ill maintain Worker's Compensation Insurance,as provided lox by Sq.FI Flnnr Arca:0 Vsluatiun:57300
Section 3700 n1'the labor Code. Ibr Elie performance of the work for which this
permit is issued.
:\I'N Number: 3G9U 102G.U(I Ocaquuwy'I}'pr:
APPLICANT CP:10 IFICAf10,N
I ccrtilp that I have read This application and stale that the above information is
correct. I agree to cnrph. with all city and county ordinances;md stale laws relatin_
m building construction.and hereby authorize representatives oflhis city to enter PERMITEXPIRES IF WORK IS NOT STARTED
upon the above mentioned propeny lir inspection purposes. (We)agree to save
indemnify and keep harmless tile City ofCupeninoagainslliabilides,judgments. WITHIN 180DAYS OFPERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence ofthe 180 DAYS FROM LAST CALLED INSPECTION.
grantimg or this permit. Additionally,the applicant understands and will contph'
with all nun-1)01111 source regulations per talc Cupertino Municipal Code.Section
9.18. Issued bv: Un le:
Si_nalure Date
â
OWNER-BUILDER DECLARA ZION I(k:ROOFS:
All roofs slhall be inspected prior to any ruuhng material being itutalled. H it roof is
hereby affirm that I am exempt from the Contractor's License Law far one of installed without lint obtaining an inspection, I agree to ocinuce all new materials Ibr
the fnllowi nK nvo reasons: inspection.
L it,owner ol'the properly,or my employees with wages as their sole connpensalion,
lyill do the work,and tike structure is not Intended or offered for sale(Sec.7044. Signor ffe of Applicant: Dale:
liminess K Professions Code)
I,as owner til tine propeny,ani cxalusively contracting with licensed contractor-,l0
construct the project(See 7044.Business R Professions Code). :\LI-ROOF CON ERINGS'1 O 111.'CLASS"V Olt BFI-1 ER
hereby affirm tinder penalty of perjury one of the fullowin?three
II:\%.\RDOUS NL\fF:RI:\I,S DISCLOSURE ra lions:
I have and will maintain it Certificate of Consent to sctf-insure Rx Worker's 1 have read(he hazardous materials requirements under Chapter 0.95 ill"file
Compensation.as provided for by Section 3700 of the Labor Code, for the Collifornia Ileallh J Safety Code.Sections 25505,25533.and 25534. 1 S,ill maintain
performance of the work fir sshich this permit is issuedcompliance with the Cupertino Municipal Code,Chapter 9.12 and the lle:dth S
I have and will maintain Wurkcr's Compensation Insurance as provided fior by S;l'el)'Curie.Section 25532(:)should I slurs or handle haiatrdons material.
Section 3700 ol'Ehe Labor Code Thr the pertbrmmtice of the work for which this Additionally,should I use equipment or devices which emit hazardous air
lenuil is issued. cull In 111i lilt[its as defined by the Ila):\rea Air Quality Nlanagemcnl 115 inct 1 sill
1 maintain compliance%%illi the Cupertino Municipal Code.Chaplet 9.12 and the
I certify that in the perlbrmance ol'the work Ibr which this permit is issued.I shall Ileatllh x Salyer, Cale,Sections 255115,25533,and 25534.
not employ amt person in any manner so its to become subject a,the Worker"s
Conhpensatiam Encs of Caldorntia. 11',after making this certificate of exemption.1 (hs ner or authorized agent,
become subject Eo the Worker's Cumpatsaimn provisions of the labor Code,I Mout Dntc:
loxlhw'dh comply will such provisions or this permit shall be deemed revoked.
CONS'I'RUC I ION LENDING AGEM I
APPLIC:\N'f CER IIkICAI[ON I Ihcrchy allirnh that there is a constnndion lending agency Ibr the perlornnncc d vwrk's
I cerlfY that I have read this application and stale that Elie above inforlrlatlml Is I'm ss'hich this panni)is issued(Sec. 3097,Civ C.)
correct. I agree to comply will,all city and county ordinances laid suds la%%s relining Lender's Name
to building construction-and herehy authorize representatives ofilhis city to enter
upon Elie above mentioned property lir inspection purposes.(We)agree Eo save Lender's Address
indcnmil)'and keep harmless the City ol'Cuperino against liabilities,judgmats,
costs,and expenses which nhay accrue against said Cit) in consequence oI the
granting of this pennil.Additionally,the applicant understands and will connply .\RCIll'I'I!Cl'S UECL:U(:VIION
\\1111 all non-paint source regulaiians per Elie Cupertino Municipal Code.Section I understand nn plans Shull be Used;IS public records.
9.18.
Licensed Prol"essiunal
Signmure Date