09070109CTTY OF CUPER'1'11vu
BUILDING DIVISION PERMIT + :
PERMIT NO.
BUILDING ADDRESS:
10455 S DE ANZA BLVD. TBD - TO BE DE
PERMIT ISSUE DATE
OWNER'S NAME:
S A CONTROL NO.
,ON
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
al _ Job Description
I hereby affirm deI am licensed under provisions of Chapter 9 (commencing
with Section 70(X)) of Division 3 of the Business and Professions Code, and my license is I N S T L 1 SET OF I LLUM WALL LTR S , RFAC E EXTNG
in full force and eftecY� 'd Q 0
License ass ` its - TENANT
Date �n�or
A ARCHiTECTSDECLARA pANLS IN MONNMT SIGN& INSTL RECVNG SIGN& HRS SIGN
l u ( nd dry Plans shall be used as public records
Profc"IMAGE IMAGE NATIONAL, INC. PD BSL 1 / 15 / 09
Licensedssional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, Business and professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the previsions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollar (5500).
❑ 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. 70", Business
and Professions Coda: The Contractor's License Law does not apply to an owner of
Property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements arc not intended or offered for sale. If.
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as owner of the property. am exclusively contacting with licensed contractors to
construct the project (See. 70". Business and Professions Code:) The Contractor's Li-
ccnae Law does not apply to an owner of property who builds or improves themon, and
who contracts for such projects with a contractar(s) licensed pursuant to the Contractor's
License Law' B & P C for this Mason❑ I am exempt under Sec
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, 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 required by Section
3700 of the Labor Cook:, for the performance of the work for which this permit is issued.
My Wor s Comp on Insurance camcrAnddPPo icy number
Amer ,4 tone} n
Cf Iifl ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section treed not be completed if the permit is for anc hundred dollars ($100)
or less.)
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 Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation Provisions of the Labor Code, you must
,J `j-, forthwith comply with such provisions or this permit shall be deemed revoked.
7-0 CONSTRUCTION LENDING AGENCY
[~.r 4 1 hereby amrm that them is a construction lending agency for the performance of
the work for which this Permit is issued (Sec. 3097, Civ. C-)
W A Lender's Name
z Lender's Address
U 0 I certify that I have read this application and state that the above information is
[I. cormcL I agree to comply with all city and county ordinances and state laws relating to
v building construction, and hereby authorize representatives of this city to enter upon the
0 W above -mentioned property for inspection purposes.
a (We) agree to save, indemnify and keep harmless the City of Cupertino against
,E "y C.4) liabilities, judgments, costs and expenses which may in any way scenic against said City
U Z in consequence of the granting of this permit.
o APPLICANT UNDERSTAkDS AND WILL COMPLY WITH ALL NO ft
POI
SOURCE RECUL.AMON '�-PO
Signature of Applicant/Contractor mic
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
❑ Yes a
Will the applicant future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Managemcm
District?
❑ ya o
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor
nia Health & Safety Code. Sections 25505.25533 and 25534. 1 understand that if the building
does not currently have a tenant. that it is my responsibility to notify the occupant of the
requirements which must I prior to ias ce of a Certificate of �Occupancy.
/L�A z
Owner or authorized agent Date
Floor
35917019.02
Issued by:
Re -roofs
Type of Roof
a
Required Inspections
Date
Type
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.
Signature of Applicant
All roof coverings to be Class';FF or better
Date
I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10455 S DE ANZA BLVD
OWNER'S NAME: CALI REAL ESTATE LLC
OWNER'S PHONE: 4017651500
❑ LICENSED CONTRACTOR'S DECLARATION
License Class 167 Lic. # (J -96 G ( O
Contractor 9,�,k Ofcc,' i e -."I k. Date Q -/ 7
1 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 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.
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.
Signatu Date 9' �? �C(
❑ OWNER -BUILDER DECLARATION
I 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 (See.7044,
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
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.
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
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.
CONTRACTOR: BUSH DECOR & PERMIT NO: 09070109
CONSTRUCTION
4431 W 8200 S DATE ISSUED: 09/17/2009
WEST JORDAN, UT 84088 PHONE NO: (801)280-0424
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB F
MECH r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: RELOCATE OF PHOTOLAB AND CHECKSTANDS
FOR
CVC/PHARMACY
Sq. Ft Floor Area: Valuation: $50000
APN Number: 35917019.55CVC Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued b : Datet-,-5-
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection,) agree to remove all new materials for
inspection.
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
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, 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
Health & Safety Code, Sections 25505, 25533, and 25534.
O r siaad-agent:
(' Date: 9 — l 7 —v%
V .
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.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date
Licensed Professional