10010012CITY OF CUPERTINO BUILDING PERMIT
[BUILDING ADDRESS: 21275 STEVENS CREEK BLVD STE 501
V- - ER'S NAME: MODENA INVESTMENTS
OWNER'S PHONE: 7082555002
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
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:
t. 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
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
t. 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:
t. 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. 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
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
CONTRACTOR: MR. RESCUE PLUMBING PERMIT NO: 10010012
& ROOTER
4231 13USINESS CENTER DR STE 12 DATE ISSUED: 05/12/2010
FREMONT, CA 94538 PHONE NO: (877) 417-3728
JOB IIESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
MINOR PLUMBING FOR HAND WASH SINK REQUIRED BY
HEALTH DEPARTMENT -BLUE LIGHT CINEMA (THEATERS)
AZI
Sq. F t Floor Area: Valuation: $4250
APN Number: 32627035.500 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
p• the above mentioned property for inspection purposes. (We) agree to save
nify and keep harmless the City of Cupertino against liabilities, judgments,
costs and expenses which may accrue against said City in consequence of the
grant .ng of this permit. Additionally, the applicant understands and will comply with
all nun -point source regulations per the Cupertino Municipal Code, Section 9.18.
Signature Date
PERMIT EXPIRES IF WORK IS NOT STARTED
'►WITHIN 180 DAYS OF PERMIT ISSUANCE OR
.L80 DAYS FROM LAST CALLED INSPECTION.
Issu .-d by:
Date:
RE -ROOFS:
All r )ofs 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
inspo -ction.
Signature of Applicant: Date
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
Cal fornia Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
corr pliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Ads litionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Hes.lth & Safety Code, Sections 25505, 25533, and 25534.
Owner 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.)
Lvider's Name
Le ider's
ARCHITECT'S DECLARATION
I u iderstand my plans shall be used as public records.
Li,:ensed Professional
_ _-—____"........�.sr� noT,fiT
CITY OF C INO BILDI
L NG PE
CO RNT ACTOR: TBD - TO BE DETERMINED I PERMIT N6'-I`@&W-F66 ,
BUILDING ADDRESS: 21275 STEVENS CREEK BLVD STE ilk
O' '�R'S NAM" II" A UJT t T
1 ON IS PHONE: 4083147357
LICENSED CONTRACTOR'S DECLARATION
icense Class Lic. # Z2�
Date It
ontractor
hereby affirm that I am licensed under the provisions of Chapter 9
:ommencing with Section 7000) of Division 3 of the Business & Professions
:ode and that my license is in full force and effect.
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
:ompensation, as provided for by Section 3700 of the Labor Code, for the
ierformance of the work for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as provided for by
lection 3700 of the Labor Code, for the performance of the work for which this
)ermit 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.
Si -nature
Date I U
L OWNER -BUILDER DECLARATION
DATE ISSUED:..04L3 AaW
i
PHONE NO:
WILI►ING PERMIT INFO: BLDG ELECT r— PLUMB
MECH r- RESIDENTIAL T_ COMMERCIAL
IOB EESCRIPTION: REPLACE TWO EXISTING COMMERICAL SINKS
Sq. Ft Floor Area: Valuation: $600
APN Plumber: 32627035.510&520 Occupancy Type:
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)
1, 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:
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.
1 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 1 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
,loon the above mentioned property for inspection purposes. (We) agree to save
emnify and keep harmless the City of Cupertino against liabilities, judgments,
and expenses which may accrue against said City in consequence of the
.iting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Sianature
PERMIT EXPIRES IF WORK IS NOT STARTED
`VITHIN 1 0 DAYS OF PERMIT ISSUANCE OR
180 DA ROM LAST CALLED INSPECTION.
Issued by: —2,v —7P—Date:
RE -ROOFS:
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
inspection.
Sign,iture of Applicant:_
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have 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 &
Safi ty Code, Section 25532(a) should I store or handle hazardous material.
Adc itionally, should I use equipment or devices which emit hazardous air
con :aminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
He: Ith & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized ent: .Ld ZO(
� Date:
CONSTRUCTION LENDING AGENCY
I hcreby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Le ider's Name
Le ader's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professio