10050098CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10101 N DE ANZA BLVD
CONTRACTOR: PRINCIPAL BUILDERS, INC
PERMIT NO: 10050098
OWNER'S NAME: 4 CORNER PROPERTIES
240 STOCKTON ST
DATE ISSUED: 08/03/2010
OWNER'S PHONE: 4153984196
SAN FRANCISCO, CA 94108
PHONE NO: (415) 434-1500
LICENSED CONTRACTOR'S DECLARATION
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BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class ic. #1 0�
1 ��.I t 1^ f l0
Contractor 1' in Ct l rl ate 17-13
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MECH RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of thapter 9
JOB DESCRIPTION: AL TI FLRS 14 & GARAGE,OFFICE RE -STACK,
(commencing with Section 7000) of Division 3 of the Business & Professions
RELOCATED
Code and that my license is in full force and effect.
SERVER ROOM, NEW OFFICES, NEW FINISHES &
LIGHTING.(5245I SQ)
I hereby affirm under penalty of perjury one of the following two declarations:
[ 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: $1500000
permit is issued.
APPLICANT CERTIFICATION
APN Number: 32630071.FLR I A.GARAGE
Occupancy Type:
I certify that I have read this application and state that the above info tion 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 proposes. (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 h may accrue against said City in consequence of the
granting of this p t. Additionally, th ap 'cant understands and will comply
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-poin our a regultins the rtino Municipal Code, Section
180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date �/
Issued by: Date:
❑ OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of
RE -ROOFS:
the following two reasons:
All roofs shall be inspected prior to any roofing material being installed. if a roof is
I, 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
will do the work, and the structure is not intended or offered for sale (Sec.7044,
inspection.
Business & Professions Code)
I, 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:
HAZARDOUS MATERIALS DISCLOSURE
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 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 Code, Sections 25505, 25533, and 25534. 1 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 &
Safety Code, Section 25532(a) should I store or handle hazardous material.
permit is issued.
Additionally, should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued, I shall
con 'nants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's
m nt in complian h he Cupertino Municipal Code, Chapter 9.12 and the
Compensation laws of California. If, after making this certificate of exemption, [
eal & Saf d S 5505, 25533, and 5534.
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.
O
YO
Date:
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
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
I hereby affirm that there is a construction lending agency for the performance of works
to building construction, and hereby authorize representatives of this city to enter
for which this permit is issued (Sec. 3097, Civ C.)
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Lender's Address
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.
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date
Licensed Professional