B-2016-1735CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1735
10200 JOHNSON AVE CUPERTINO, CA 95014-3812 (375 25 066) DE ANZA BUILDERS
SAN JOSE, CA 95129
OWNER'S NAME: MATHEW THOMAS
OWNER'S PHONE: 408-261-8820
LICENSED CONTRACTOR'S DECLARATION
License Class GENERAL BUILDING CONTRACTOR Lic. #943227
Contractor DE ANZA BUILDERS Date 02/28/2018
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.
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 again liabilities, judgments, costs, and expenses which
may accrue against sad ity in consequence of the granting of this permit.
Additionally, the applic r understands and will comply with all non -point
source regulations per h Cupertino Municipal Code, Section 9.18.
Date 1/1
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 (Sec7044, Business & Professions Code)
2. 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:
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 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 41/ 1/16
ISSUED: 04/11/2016
PHONE NO: (408) 865-0222
BUILDING PERMIT INFO:
X BLDG —ELECT _ PLUMB
MECH X RESIDENTIAL COMMERCIAL
JOB DESCRIPTION:
TEMPORARY SHORING
Ft Floor Area: I Valuation: $18000.00
APN Number: Occupancy Type:
375 25 066
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by: Abby Ayende b ���
Date: 04/11/2016
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.
Signature of Applicant:
Date: 4/11/16
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 Munic' Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) shou d I tore or handle hazardous
material. Additionally, should I use equipmen or vices which emit hazardous
air contaminants as defined by the Bay Area Q ality Management District I
will maintain compliance with the Cupertino un cipal Code, Chapter 9.12 and
the Health & Safety Code, Spetion 255 5, 25533, and 25534.
r or authorized agent:
4.1/ 1/16
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
ARC'HITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
Professional
CUPERTINO
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 T ORRE AVENUE • CUPERTINO, CA 950'14-3255
(408) 777-3228 • FAX (408) 777-3333 • buil dino(5?cupertino. org
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By my c,E,:nat'are below, I certi;y to each of the follo-� ing: I ani the property owner or authorized agent to act' he property wwner's behalf. I have read this
application and the information I have provided is o, • ect. I have read the Description of'Work and ve_i y it is accurate. I a_ree to con_ply V. ith all applicable local
ordinances and state laws relating to buildi oast tion. I authorize rep se:rtatives of Cupertino to enter the above -identified property'or inspection purposes.
Signature of Apphcant/A_ent: f Date: �" x�
SLirP .E-\dENTAL II\�FOR-I\4_ATIG ,� REQUIRED
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submittal of Building Permit apps-icatioit.
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