10070132CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22840 MERCEDES RD
CONTRACTOR: DEVCON CONSTRUCTION
PERMIT NO: 10070132
INC
OWNER'S NAME:
MILPITAS, CA 95035
PHONE NO: (408)942-8200
I LICENSED CONTRACTOR'S DECLARATION
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BUILDING PERMIT INFO: BLDG ELECT PLUMB
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License Class 10Lic. # Jgci i &O 3
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Contractor MWA-`A cQA$J U0%00 Date e[-S17_Q0
MECH RESIDENTIAL COMMERCIAL'
1 hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: REMODEL OF 9 1/2(E) BATHROOMS INCLUDING
(commencing with Section 7000) of Division 3 of the Business & Professions
RELOCATION
OF PLUMBING FIXTURES, SMALL WALL MODIFICATIONS,
Code and that my license is in full force and effect.
LIGHTING, PATIO, NEW CABINETS (445SQ)
1 hereby affirm under penaIty of perjury one of the following two decIarations:
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: $210000
permit is issued. M
APPLICANT CERTIFICATION
APN Number: 34222109.00
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
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 said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non -point source regulations per the Cupertino Municipal Code, Section
180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature_ Date ¢1 D
�j
Issued by-✓ Date:r�
❑ OWNER -BUILDER DECLARATION
1 hereby affirm that 1 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
wilt 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:
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 Code, 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 HeaIth &
Safety Code, Section 25532(a) should 1 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
contaminants as defined by the Bay Area Air Quality Management District 1 will
not employ any person in any manner so as to become subject to the Worker's
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Compensation laws of California. If, after making this certificate of exemption, I
Health & Safety Code, Sections 25505, 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.
Own agent:
Date:�c2
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
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 work's
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_ Dale
Licensed Professional
I CITY OF CUPERTINO 13UILDING PERMIT I
BUILDING ADDRESS: 22840 MERCEDES RD I CCO 1ONST14TRUCT ON INC CON I PERMIT NO: 10070132 I
OW-'ER'S NAME:
MILPITAS, CA 95035 PHONE NO: (408)942-8200
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
RED IODEL OF 9 1/2(E) BATHROOMS INCLUDING RELOCATION
License Class Lic. # OF'LUMBING FIXTURES, SMALL WALL MODIFICATIONS,
LIGHTING, PATIO, NEW CABINETS (445SQ)
Contractor
Date
I hereby affirm that I 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.
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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.
2. 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 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
Date
L OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
1. 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)
2. I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations:
1. 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.
2. 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.
3. 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
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.
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
inify and keep harmless the City of Cupertino against liabilities, judgments,
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 Date
10/11/2010- REV#2 - REVISION OF TRUNCATED DOME AT MAIN ENTRY
5 rae /,) /,/// A-0
09/(7/2010 - REV#1 - REMODEL OF ONE RESTROOM-REV#1 ISS'D 09/08/2010
Sq. Ft Floor Area: I Valuation: $210000
AP J Number: 34222109.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM, LAST CALLED INSPECTION.
Iss ted by:
Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
instilled without first obtaining an inspection, I agree to remove all new materials for
insl ection.
Sig tature of Appli
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I h:.ve read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Saf!ty Code, Section 25532(a) should I store or handle hazardous material.
Ad,litionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
ma ntain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Ow ner or authorized agent:
Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lei der's Name
Lei.der's Address
ARCHITECT'S DECLARATION
I ur derstand my plans shall be used as public records.
Lic!nsed Professio