10120142I CITY OF CUPERTINO BUILDING PERMIT I
I BUILDING ADDRESS: 10615 S DE ANZA BLVD I CONTRACTOR:
ONTRDEVELC OR' PROVISION I PERMIT NO: 10120142 I
OWNER'S NAME:
S DECLARATION
License Class Lic. # ` a -
Contractor. 1 Date J
I hereby a rtn that I am licensed under the provisi ns of hapter 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:
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.
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 li_iitties, judgments,
costs, and expenses which may accrue against said it asequence of the
granting of this permit. Additionally, the c derstands and will comply
with all non -point source regulati er t upertino Municipal Code, Section
9.18.
Signature Date L
❑ OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1 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, 1 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,
Date: v 2G
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is wconstruction 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
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10615 S DE ANZA BLVD
CONTRACTOR: PROVISION
PERMIT NO: 10120145
DEVELOPMENT, INC.
OWNER'S NAME:
SUNNYVALE, CA 94086
PHONE NO: (408) 245-0991
❑ LICENSED CONTRACTOR'S DECLARA'T'ION
BUILDING PERMIT INFO: BLDG
(r
License Class ?j
ELECT PLUMB
Lie. #J
MECH RESIDENTIAL
Contractor 1 100 Z% C9 I
COMMERCIAL
1 Date 29 f
r
I hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: S ITE C, 50 SF, ALTER EXISTING BUILDING WITI-1 NEW
(commencing with Section 7000) of Division 3 of the Business & Professions'
T-BAR CEILING, NEW LIGHTING, ONE DEMINSING WALL,
Code and that my license is in full force and effect.
ONE STORAGE ROOM, MODIFY DIFFUSERS, REPLACE ONE
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 die 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
Sq. Ft Floor Area:
Valuation: $12000
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APN Number: 35918044.00
Occupancy Type:
APPLICANT CERTIFICATION
1 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 liab 'ties, judgments,
PERMIT EXPIRES IF WORK IS NOT STARTED
costs, and expenses which may accrue against sai Cj:" sequence of the
granting of this permit. Additionally, th ican erstands and will comply
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS
with all non-
17
i
Issued b�: Date: P K
❑ OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
installed without first obtaining an inspection, I agree to remove all new materials for
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:
I have and will maintain a Certificate of Consent to self-insure for Worker's
HAZARDOUS MATERIALS DISCLOSURE
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 & Safetyode, Sections 25505, 25533, and 25534. I will maintain
1 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(11) should 1 store or handle hazardous material.
permit is issued.
uipment or devices which emit hazardous air
Additionally, should I use a�he
I certify that in the performance of the work for which this permit is issued, 1 shall
contaminants as defined by BayArea Air Qual' y Management District I will
maintain compliance with te Cupert' pal Code, Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
forthwith comply with such provisions or this permit shall be deemed revoked.
ate:
/
APPLICANT CERTIFICATION �
CONSTRUCTION LENDING
G 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 work's
correct. I agree to comply with all city and county ordinances and state laws relating
for which this permit is issuedi(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
with all non-point source regulations per the Cupertino Municipal Code, Section
ARCHITECT'S DECLARATION
9.18•
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional
�...� -
CITY OF CUPERTINO BUILDING PERMIT DATE
BUILDING ADDRESS: 10617 S DE ANZA BLVD
CONTRACTOR: PROVISION
PERMIT NO: 10120143
DEVELOPMENT, INC.
OWNER'S NAME:
SUNNYVALE, CA 94086
PHONE NO: (408) 245-0991
❑ LICENSED CONTRACTOR'S DECLARATION
r rr
BUILDING PERMIT INFO: BLDG r
c
License Class �� Lic. # p
ELECT PLUMB
MECH f— RESIDENTIAL F_ COMMERCIAL r
Contractor �Z� fDate
I hereby;affirm:that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: SUITE B, 50 SF, ALTER EXISTING BUILDING WITH NEW
(commencing with Section 7000) of Division 3 of the Business & Professions
T -BAR CEILING, NEW LIGOTING, ADD ONE ADA RESTROOM,
Code and that my license is in full force and effect.
MODIFY DIFFUSERS, REPIACE ONE WINDOW W/NEW
3/2/11-REV#I-RELOCATE1OILET FROM ORIGINAL PLAN- 3/2/11-REV#I ISSD
1 hereby affirm under penalty of perjury one of the following two declarations:
OVR COUNTER
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.
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
Sq. Ft Floor .Area:
Valuation: $25000
permit is issued.
APPLICANT CERTIFICATION
APN Number: 35918044.10617
Occupancy Type:
I certify that I have read this application and state that the above information is
correct. 1 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,
PERMIT EXPIRES IF WORK IS NOT STARTED
costs, and expenses which may accrue against ss n consequence of the
granting of this permit. Additional) pple� i understands and will comply
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with
9.18. all non -point source re ons per upertino Municipal Code, Section
180 DAYS FROM LAST CALLED INSPECTION.
Signatu,>
Issued by:
Date:
❑ OWNER -BUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Law for one of
RE -ROOFS:
the following two reasons:
1, as owner of the property, or my employees with wages as their sole compensation,
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
will do the work, and the structure is not intended or offered for sale (Sec.7044,
inspection.
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
Signature of Applicant: Date:
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance, as provided for by
California Health & Safety C1ode, Sections 25505, 25533, and 25534. I will maintain
Section 3700 of the Labor Code, for the performance of the work for which this
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
permit is issued.
Safety Code, Section 25532(a should I store or handle hazardous material.
I certify that in the performance of the work for which this permit is issued, I shall
Additionally, should I use egi1ipment or devices which emit hazardous air
contaminants as defined by the Bay Area Quality Management District I will
AlCu
not employ any person in any manner so as to become subject to the Worker's
maintain compliance with the unicipal Code, Chapter 9.12 and the
Zompensation laws of California. If, after making this certificate of exemption, I
Health &Safety Code, S 5, 25533, and 25534.
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.
Owner
Date:
APPLICANT CERTIFICATION
certify that I have read this application and state that the above inform tion is
CONSTRUCTION LENDING AGENCY
;orrect. I agree to comply with all city and county ordinances and state laws relating
I hereby affirm that there is a construction lending agency for the performance of work's
o building construction, and hereby authorize representatives of this city to enter
for which this permit is issued (Sec. 3097, Civ C.)
ipon the above mentioned property for inspection purposes. (We) agree to save
Lender's Name
ndemnify and keep harmless the City of Cupertino against liabilities, judgments,
:osts, and expenses which may accrue against said City in consequence of the
Lender's Address
;ranting of this permit. Additionally, the applicant understands and will comply
vith all non -point source regulations per the Cupertino Municipal Code, Section
1.18.
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
signature Date
Licensed Professional