11070009 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20530 TOWN CENTER CONTRACTOR:-- PERMIT NO: 11070009
OWNER'S NAME: CIVIC PARK CUPERTINO LLC �� l DATE ISSUED:08/10/201 I
OWNER'S PHONE: 4084363671 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATIONF
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.N Q — d� T T r`
MECH RESIDENTIAL COMMERCIAL
Contractor/V `/'fi/_ JQ Date Q
I hereby affirm that I am licensed under the provisions of Ch Ater 9 JOB DESCRIPTION:CUPERTINO ORAL SURGERY-(BETWEEN AMICI&
(commencing with Section 7000)of Division 3 of the Business&Professions ORTHODONTIST}COMM.T.l(I 196SQFT)FOR NEW DENTAL
Code and that my license is in Cull force and effect. OFFICE ACCESSIBLE RESTROOMS SUSPENDED CEILING
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 Sq.Ft Floor Area: Valuation:$120000
permit is issued.
APPLICANT CERTIFICATION APN Number:36955082.20530 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued ' Date:
Signature Date
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,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
[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 1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner A authorized a ent: r��l/) / r/
forthwith comply with such provisions or this permit shall be deemed revoked. JA Date: (((
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of wrk's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
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
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO BUILDING PERM&TE d
BUILDING ADDRESS: 20530 TOWN CENTER CONTRACTOR:BDN CONSTRUCTION PERMIT NO: 11070009
CORPORATION
OWNER'S NAME: CIVIC PARK CUPERTINO LLC 2068 LADDIE WAY DATE ISSUED:08/10/2011
O ER'S PHONE: 4084363671 SAN JOSE,CA 95121 PHONE NO:(408)531-7481
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL
License Class C- O ` Lic.4 S_73_->_�,O CUPERTINO ORAL SURGERY-(BETWEEN AMICI&
Contractor Date C)'
( ( ORTHODONTIST)-COMM.T.I(1196SQFT)FOR NEW
DENTAL
I hereby affirm that 1 am licensed under the provisions of Chapter 9 OFFICE ACCESSIBLE RESTROOMS SUSPENDED CEILING
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect. 10/3/2011-41-DEFERRED SUBMITTAL FOR MEDICAL GAS
1 hereby affirm under penalty of perjury one of the following two declarations: DIAGRAM&COMPLETE SPECIFICATIONS-ISSD 10/14/2011
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. Sq.Ft Floor Area: Valuation:$120000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor C , r the performance of the work for which this APN Number:36955082.20530 Occupancy Type:
permit is issued. or
APPLI ANT CERTIFICATION
I certify that I have re this ap lication and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.1 agree to CO.
o ply wi all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construc'on,an hereby authorize representatives of this city to enter
upon the above me lone roperty for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and kee h ess the City of Cupertino against liabilities,judgments,
costs,and expense may accrue against said City in consequence of the
granting of this pe ditionally,the applicant understands and will comply Issued by: ate:
with all non-point urce gulaticns per the Cupertino Municipal Code,Section
9.18. /7
Iv .` RE-ROOFS:
rfs shall be inspected prior to any roofing material being installed.if a roof is
led without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERYALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials req er ents under Chapter 6.95 of the
California Health&Safety Code,Sectio s 505,25533,and 25534. I will
1 hereby affirm under penalty of perjury one of the following three maintain compliance with the Cuperti unicipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532( ould I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use a pment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the B rea Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with the a tino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectio 5 5,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Oto-
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 CONSTRUCTION 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 permit 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 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, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I understand my plans shal I be used as 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