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09100076CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10991 N DE ANZA BLVD CONTRACTOR: XL CONSTRUCTION PERMIT NO: 09100076 OWNER'S NAME: STAR ONE CREDIT UNION 851 BUCKEYE CT DATE ISSUED: 10/26/2009 OWNER'S PHONE: 4082406431 MILPITAS, CA 95035 PHONE NO: (408)271-2425 ❑ LICENSED CONTRACTOR'S DECLARATION r r— INFO: —N BUILDING PERMIT BLDG ELECT PLUMB License Class Lic. # A&C1 MECH F RESIDENTIAL r COMMERCIAL � Contractor &*—bate (0 Z-0 1 I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:COMM'L TI EXPAND ROOM FOR INSTALLATION (commencing with Section 7000) of Division 3 of the Business & Professions OF Code and that my license is in full force and effect. ADDITIONAL ATM I 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. Sq. Ft Floor Area: Valuation: $20000 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. APN Number: 32610059.00 Occupancy Type: APPLICANT CERTIFICATION I certify that 1 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 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 which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. II Issued b DateG Z�r SignatureDate 1 ❑ OWNER -BUILDER DECLARATION RE -ROOFS: All roots shall be inspected prior to any roofing material being installed. If a roof is I 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 structure is not intended or offered for sale (Sec.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 "A" OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE I have and will maintain a Certificate of Consent to self -insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the Compensation, as provided for by Section 3700 of the Labor Code, for the California Health & S@fety Code, Sections 25505, 25533, and 25534. I will maintain performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & 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 equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued, I shall Health & Safety Code, Sections 25505, 25533, and 25534. 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 or ttLLriz.d a e �(9 become subject to the Worker's Compensation provisions of the Labor Code, I must AA Date: ©� forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I hereby affirm 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. 1 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, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply ARCHITECT'S DECLARATION with all non -point source regulations per the Cupertino Municipal Code, Section I understand my plans shall be used as public records. 9.18. Licensed Professional SignatureDate