12070157CITY OF CUPERTINO BUILDING ]PERMIT
BUILDING ADDRESS: 23500 CRIShO REY DR
CONTRAC`fOR: BAY AREA
PERMf1' NO: 12070157
ENTERPRISE
OWNER'S NAME: THE FORUM RANCHO SAN ANTONIO
2110 MANGIN WAY
DATE ISSUED: 07/19/2012
OWNER'S PHONE:
SAN JOSE, CA 95148
PIIONF. NO: (408)238-5043
LICENSED C0 1'RA(-fOR'S DECLARATION
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4i 1 I
BUILDING PERMIT INFO: BLDG ELF -Cr PLUMB
License Class Lie. 9 1 1
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aIECU RF.SIDENI'LV- COMMERCIAL
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Contractor PJ�u kr.ta EP 1 Datc�)6,jr20/2
3011 DESCRII''1'1 ON: LEVEL N2- 1i1.liVA'FOR STORAGSTORAGE.-ARBA- ADD NI3W' 20
I hereby affirm that 1 ant licensed under the provisions of Cha ptcr 9
VIA
AMP VIA EMT
(commencing with Section 7000) of Division 3 of the Business C Professions
STORAAGEGE ARP /14 -ADD NIi1V 20 AMP OUFI.Ii'1' VIA E\1T
Cade and that tar license is in full force and effect,
STAFF BREAK ROOM. ADD NEW PLUG FOR T.V
CONFERENIE ROOM- ADD NI:W OU'rl.1i'r 20 Ai\1P CHANGE EXISTING TO
1 hereby affirm under penalty of perjury one of the following two declarations:
DOUBLE BOX/OUTLET
I h: ve and will maintain a certificate of consent to self -insure Im Worker's
Compensation, as provided for by Section 3700 of the Labor Code. Inc the
Sq. 1'1 Floor Ares
Valuation: $750
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
AI'N Number: 34254999.00
Occu pancy'1}pr.
permit is issued.
\1'1'1:1 C\NPI' CF:12'I'IPIC,\TIO\
I cenify that l have read this application mid state that the above information is
PERMITE\PIRES IF WORK IS NOT STARTED
correct. l agree to comply with all city and county ordinances and state law's relating
WITHIN 180 DAYS OF PERD7IT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DA ROM LAST CALLED INSI3 • CT ON.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Issued by: Y L Dale:: %/� JZ.
granting of this permit. Adilio .Ily, the applicant understands:tad will comply
with all non -point sat ego ions per the Cupertino Municipal Code, Section
RF: ROOFS:
9.18.
I ,0 / � d/
Signature Date / t1=G 2,
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby tiff rat that l atm ryrmplfrom the Contractor's License Lao for one of
the following nwo reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BE FER
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business Z Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
IIA%ARDOUS MATERIA S DISCLOSURE
construct the project (Sec.7044, Business K Professions Code).
I have read the hazardous materials requirements under Chapter -6.95 of the
California Health R Safetv Code. Sections 25505, 25533. and 25534. I will
1 hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino \lunicipal Code, Chapter 9.12 and the
declamations:
Ilealth S Safely Code. Section 25532(3) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self insure for Worker's
material. Addition'.11y, should I use equ' hoc hl or devices which emit hazardous
Compensation, as provided for by Section 3700 of tine labor Code, for the
air coamminants as defined M• the Iitl rc \' utility Management District I
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
will maintain compliance with tile p e Cut . lunici ode. Chapter 9.12 and
the Health & Safe[ 25533 it 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner -111,512,0
Permit is issued.
or authorized agent:
I certify tial in the performance of the work for which this permit is issued, I shall
not employ any person in my manner so as to become subject to the W'orker's
Compensation laws of California. If after making this certificate of exemption, I
CONS'I'RUC-11ON LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending- agency for the performance of
forthwith comply with such provisions or this pernia shall be deemed revoked
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state dial 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 this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
,UK:111'1'h;Cl"S DECLARATION
and keep harmless the City of Cupertino against liabilities. judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used its public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CONSTRUCTION PERMIT APPLICATION n,�0x5
COMMUNE GEVELOPMEN i P. RTME.V i • BUILDING C-N!SiON
10300 TORRE AVENUE - CUPER I INC. CA 95014-3255
CUPERTINO ' (408) -/T7-3228 - FAX (4081 TT7-3333 - buildinar7r. cuoer3De om 9 1
❑ NEV CONSTRUCHON ❑ ADD-fON L'Y.L--t��;u.�/TI El RE'—�10N/Dc R -Z=') ORGLNA:_7CaWr.=
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OCL i SQ?T. I VALUATION (S)
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NEW FLoOR
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BATHROOM RI
REe1OOFZARPA R` E?600 ADL• R AREA "1o0ELw.t--a
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OASLCUND UMT ❑Y3 aRomo TORY YS
BEINGADDiat- QNO I ADDR-OM. QW
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PREAPPLMATEW ❑YS 9: YES PROVOE 00" W I MrRS3L GAN L] -'as
PSAlMM6 APPta QNO ?=J1NNarG APWDVAL L'.^.Ea I RcsLERHOw-U C3RO
RECEIVED BY:
?DIAL VA*_JAT!OIi
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H)• O}y a1gtYlWe tIG1OW. I L��y m GfS Of Ole fOLOW"J.g: I ®'IJG pmocy ORDIQ W aDZ'Or�LO after- 3] 2e: VD ;� prppey OwOQ � beitali 1 aK t� (his
appliadon and the mfmmmua I have pmvWcd s cum, lave :cad ae Dcuriptim ofWc& red ve:i y ^ is acaram I
agrc m comply with all applicable local
md'mances and state laws -daring m building ecusmlcaao. I m9ha6m rc msmmivCS of CuPertno b =— :fib above -i ed impery ferasaecdan vtnvwes
Si9naWmafAWIicmdAg= ' Dart /ZZ/;ZVf
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SUPPLEMENTAL WORMAMNREQUIRJF,'
PLAN CHEQCTYPE
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r1 OVER_tHE-COGhTirB
❑ BeaDMe PUN at•,vmw
New SFD orMDltifmmly dweIlmgs: Apo'ryfor aemoGcoD peRm t fer
axmng bmldines1. Demalipan platen LS EGcI. pf:ar STD issuance of building
permit for new bmldmg.
❑ EXPRESS
❑ PLL` WC PLa V REVIEW
_ Cot .'al Bldgs: Provide a w®Icmd Hazardmu Maa:as Discicsu e
❑ sTnnanRD
❑ POsuc wom s
form if any Hazardous Matmals am, bceg used as Part of -`wis Ptplect
❑ LARGE
❑ rtes nrsr
_ Copy of Planriing Approval LeCer W kecdBg With Pla", ing Pr W m
EI MAIOR
❑ S.NurARY SEWER DLSTiDCT
submittal of Budding Permit =s, olimticn.
❑' E:NY 0NMEN-ML HEALTH
21d9Appi_7011.doc reYised 05/71/11
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