11060108CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10355 N DE ANZA BLVD CON-rRACTOR: ICOM PERMIT NO: 11060108
MECHANICAL INC
-VNER'S NAME: APPLE INC 477 BURKE ST DATE ISSUED: 07/07/2011
vwNER'S PHONE: 4089744876 SAN JOSE, CA 95112 PHONE NO: (408)792-2292
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. # �/Q ;� (� G
Contractor AtIl atc
1 hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued
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 this city to enter
upon the above mentioned property for inspection purposes (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source r dations per the Cupertino Municipal Code, Section
9 18
signature Datc 7 7 -1/
❑ OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 & Professions Code)
1. as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code)
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code. I must
forthwith comply with such provisions or this permit shall be deemed revoked.
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 this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
tdemnify and keep harmless the City of Cupertino against liabilities, judgments.
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
918
Signature Date
Bt'ILDING PERMIT INFO: BLDG ELECT PLUMB
NIECII RESIDENTIAL, COMMERCIAL.
JOB DESCRIPTION: REMOVE & REPLACE: CLJR13S AT 3 FXISI'ING A/C/ lJNrrS.
ADD NEW ISOLATION RAIL AND STEEL I - BEAM CLJR13S
Sq. Ft Floor Area: I Valuation: $80000
APN Number: 32633113.00 1 Occupancy'rype:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued bv• Date:
RE -ROOFS:
All rool's shall be inspected prior to any roofing material being installed If a rooks
installed without first obtaining an inspection, I agree to remove all new materials fur
inspection.
Signature of Applicant:
Date:
ALL ROOF COVERINGS -1.0 BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Ilealth & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should 1 use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Ilealth & Safety Code, Sections 25W, 25533, and 25534.
Owner or authorized agent: 4e v� Date:
101 If
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Add
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional