10040005 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10486 STERLING BLVD CONTItACTOR:TBD-TO BE DETERMINED PERMIT NO:10040005
DATE ISSUED:05/03/2010
OWNER'S NAME: CITY OF CUPERTINO INC
PHONE NO:
C. ZR'S PHONE: 4087773354 '
C, LICENSED CONTRACTOR'S DECLARATION BUIL')ING PERMIT INFO: BLDG T— ELECT F PLUMB
License Class Lic.# MECH F RESIDENTIAL F COMMERCIAL
Contractor Date
JOB])ESCRIPTION:REMOVE AND REPLACE EXISTING WOOD PROPERTY
I hereby affirm that I am licensed under the provisions of Chapter 9 LINE
(commencing with Section 7000)of Division 3 of the Business&Professions FENCI BETWEEN 10486&10476 STERLING BLVD;ELITE
Code and that my license is in full force and effect. LAND;CAPING PD FOR BUS LIC
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 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 F1 Floor Area: Valuation:$100
permit is issued.
APPLICANT CERTIFICATION Occupancy Type:
I certify that I have read this application and state that the above information is APN Vumber:37523046.00 p y yp
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, F ERMIT EXPIRES IF WORK IS NOT STARTED
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
with all non-point source regulations per the Cupertino Municipal Code,Section g0 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature
Date Issued by: • �-'—""- Date:
S OWNER-BUILDER DECLARATION
RE-ROOFS:
ZI hereby affirm that I 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:
I,as owner of the property,or my employees with wages as their sole compensation, insta led without first obtaining an inspection,I agree to remove all new materials or
will do the work,and the structure is not intended or offered for sale(Sec.7044, insp(ction.
Business&Professions Code) Sign iture of Applicant: Date:
I,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
I 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 coir pliance 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.
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 taminants 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 maintain compliance with the Ctipertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I
He:lth&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must ,� ,njer or author' d agent
forthwith comply with such provisions or this permit shall be deemed revoked. `"'��jj'' Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I he reby a
correct.I agree to comply with all city and county ordinances and state laws relating 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.)
Lender's Name
un--the above mentioned property for inspection purposes.(We)agree to save
i iify and keep harmless the City of Cupertino against liabilities,judgments, Le ider's Address
and expenses which may accrue against said City in consequence of the
:ing of this permit.Additionally,the applicant understands and will comply
w«n alln oint source reg a ons per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18. l I u iderstand my plans shall be used as public records.
Signatu Date l
Li,:ensed Professional
..e