10120044CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21979 SAN FER.NANDO AVE CONTRACTOR: CITY FACILITIES PERMIT NO: 10120044
OWNER'S NAME: CITY OF CUPERTINO 10300 TORRE AVE DATE ISSUED: 06/27/201 1
OWNER'S PHONE: 4087773215 CUPERTINO, CA 95014 PHONE NO: (408) 777-3228
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
BLACKBERRY FARM - REMODEL RETREAT CENTER ADA
License Class Lic. N RESTROOM & FRONT AREA, POOL HOUSE & RESTROOM ADA
UPGRADES; NO RE -ROOF & NO STRUCTURAL- NO
Contractor Date
1 hereby affirm that 1 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: Sq. Ft Floor Area: Valuation: $320000
1. 1 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. APN Number: 35710008.00 Occupancy Type:
2. 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
permit is issued.
PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR
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 180 DAYS FROM LAST CALLED INSP TI N.
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, Issued by: L Z Date:
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 9.18. RE -ROOFS:
Signature Date 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:
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1 1, 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 HAZARDOUS MATERIALS DISCLOSURE
sale (Sec.7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed contractors to I have read the hazardous materials requirements under Chapter 6.95 of the
construct the project (Sec.7044, Business & Professions Code). G� L California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
I hereby affirm under penalty of perjury one of the following three declarations: Safety Code, Section 25532(a) should I store or handle hazardous material.
i I have and will maintain a Certificate of Consent to self -insure for Worker's Additionally, should I use equipment or devices which emit hazardous air
Compensation, as provided for by Section 3700 of the Labor Code, for the 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
performance of the work for which this permit is issued. Health & Safety Code, Sections 25505, 25533, and 25534.
2 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 Ow or authory�ed agent:
permit is issued. ��^L`—� Date:
3 1 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 CONSTRUCTION LENDING AGENCY
Compensation laws of California. If, after making this certificate of exemption, I I hereby affirm that there is a construction lending agency for the performance of work's
become subject to the Worker's Compensation provisions of the Labor Code, 1 for which this permit is issued (Sec. 3097, Civ C.)
must forthwith comply with such provisions or this permit shall be deemed Lender's Name
revoked.
Lender's Address
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is ARCHITECT'S DECLARATION
correct. I agree to comply with all city and county ordinances and state laws relating I understand my plans shall be used as public records.
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save Licensed Professional
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 regulations per the Cupertino Municipal Code, Section 9.18.
Signature flv_ Dateb 2� ��