10010056CITY OF CUPERTINO BUILDING PERMIT
10010056
CONTRACTOR: TBD - TO BE DETERMINED PERMIT NO:
DATE ISSUED: 01/20/2010
PHONE NO:
BUILDING ADDRESS: 10555 S DE ANZA BLVD STE 125
OWNER'S NAME: MENG'S ACADEMY
r' 'ER'S PHONE: 4082579228
0 LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor
Date
I hereby affirm that I am licensed under ion 3 of the Business &Professions
he provisions of Chapter 9
(commencing with Section 7000) of Div
Code and that my license is in full force and effect.
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 Labor Code, for the
Compensation, as provided for by Section 3700 of th
performance of the work for which this permit is issued. provided for by
I have and will maintain Workers Compensation Insurance, as p
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
BUILDING PERMIT INFO: BLDG
ELECT PLUMB F
MECH F RESIDENTIAL COMMERCIAL
0
JOB DESCRIPTION: REMOVE (E) NON-BEARING LL ABOUT 30SQ & PATCH
CEILING AS NEEDED; NO RE -ROOF & NO STRUCTURAL
Sq. Ft Floor Area:
APN Number: 35918058.STE125
APPLICANT CERTIFICATION
I certify that I have read this application and state o that
es and the above info
a laws relating
ation is
correct. I agree to comply with all city and county
to building construction, and hereby authorize representatives of this entercity to
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
understands and will comply
granting of this permit. Additionally, the applicant
eme
with all non -point source,xegulations per the Cupertino Municipal Code, Section
9.18.
s , s f��✓
,o Date
Signature
L OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
is not intended or offered for sale (Sec.7044,
will do the work, and the structure
Business & Professions Code)
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:
I have and will maintain a Certificate of Consent to self -insure for Worker's
the
Compensation, as provided for by Section 3700 of the Labor
performance of the work for which this permit is issued. provided for by
I have and will maintain Worker's Compensation Insurance, as p
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
rformance of the work for which this permit �e Worker's
not
iWohall
I certify that in the pebecome subject
not employ any person in any manner so as to bject
Compensation laws of California. If, after making this certifilae Labor or Codeol mus
become subject to the Worker's Compensation provisions of
forthwith comply with such provisions or this permit shall be deemed revoked.
Valuation: $2500
Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued bye
RE -ROOFS:
All roofs shall be inspected prior to any roofing material
new materials roof
is
installed without first obtaining an inspection, I agree remove all
inspection.
Date:
Signature of Applicant:
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
st tc lawt s relating
to building construction, and hereby authorize representatives of
enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupsaid Crtino ity
tconsequence of the judgments,
C ind expenses which may accrue againsth'
g, _ .ng of this permit. Additionally, t�plicant understands and will comply
with all non -point sour% re s per the Cupertino Municipal Code, Section
9.18. >` 1
Date
Signature
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 25 33, and 25534.91 will of the
California Health & Safety Code, Sections 25505
compliance with the Cupertino Municipal Code,
Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store
clh emit hazardous a re hazardous material.
Additionally, should I use equipment or devices wh
contaminants as defined by the Bay Area Air Quality Management District I and the maintain compliance with the s 25 ert ; 25533n and 25534.
Health &Safety Code, SA-pas___�
Owner or au
Date:
__ -----
I hereby affirm that t�eis �constructio�n lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address.
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional