15070001CITY OF CUPERTINO BUILDING PERMIT
BUILIDING ADDRESS: 20065 STEVENS CREEK BLVD
CONTRACTOR: BLACK DIAMOND
PERMIT NO: 15070001
PAVING
OWNER'S NAME:. ARBOR PROFESSIONAL CENTER
23098 CONNETICUT ST
DATE ISSUED: 10/07/2015
OWNER'S PHONE: 4089712700
HAYWARD, CA 94545
PHONE NO: (510)770-1150
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
VOLUNTARY SITE ACCESSIBILITY UPGRADES (PARKING
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License Class{ #1
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Contractor r 4 C k 0;1-11A �� `,Ir Date
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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.
Sq. Ft Floor Area:
Valuation: $0
I 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
APN Number: 31623096.00
Occupancy Type:
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 EXPIRES IF WORK IS NOT STARTED
permit is issued.'
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
180 DAYS FROM LAST CALLED INSP C ION.
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
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j, rivi4d
upon the above mentioned property 3for inspection purposes. �e) agree to save
Issued by: Date:
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
RE -ROOFS:
all non -point source regulations per the Cupertino Municipal Code, Section 9.18.
„
All roofs shall be inspected prior to any roofing material being installed. If a roof is
/
Signature Date 1 `�! f j --
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installed without first obtaining an inspection, I agree to remove all new materials for
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inspection.
Signature of Applicant: Date:
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
the following two reasons:
1. 1, as owner of the property, or my employees with wages as their sole
HAZARDOUS MATERIALS DISCLOSURE
compensation, will do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
2. 1, as owner of the property, am exclusively contracting with licensed contractors to
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
construct the project (Sec.7044, Business & Professions Code).
Safety Code, Section 25532(a) should I store or handle hazardous material.
I hereby affirm under penalty of perjury one of the following three declarations:
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
1.. 1 have and will maintain a Certificate of Consent to self -insure for Worker's
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Compensation, as provided for by Section 3700 of the Labor Code, for the
Health & Safety Code, Sections 25505, 25533, and 25534.
performance of the work for which this permit is issued.
2 1 have and will maintain Worker's Compensation Insurance, as provided for by
OwM atho ' a t: )_
Date: y S
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
3. 1 certify that in the performance of the work for which this permit is issued, I shall
CONSTRUCTION LENDING AGENCY
not employ any person in any manner so as to become subject to the Worker's
I hereby affirm that there is a construction lending agency for the performance of work's
Compensation laws of California. If, after making this certificate of exemption, I
for which this permit is issued (Sec. 3097, Civ C.)
become subject to the Worker's Compensation provisions of the Labor Code, I
Lender's Name
must forthwith comply with such provisions or this permit shall be deemed
revoked.
Lender's Address
APPLICANT CERTIFICATION
ARCHITECT'S DECLARATION
I certify that I have read this application and state that the above information is
I understand my plans shall be used as public records.
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
Licensed Professional
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
CUPER-r][ tO,
❑ NEW CONS TRT ICTTnN
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228• FAX (408) 777-3333 • building(C17CUDeftino.Org
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DESCRIPTION OF WORK
EXISTINGUSE 'PROPOSED USE CONSTR.TYPE ,".STORIES
USE
TYPE ( OCC. I SQ.FT.
I VALUATION ($)
EXISTG
AREA
A -EW FLOOR,
I AREA
DEMOTOTAL
AREA
NSI' AREA
BATHROOM.
KITCHEN:
OTHER. -
-
REMODEL AREA �°i
REMODEL AREA Desi%I�
REMODEL AREA
PORCH AREA
DECK AREA
TOTALDECKIPORCHAREA
GARAGE AREA: DETACH
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9DWELLINGUNITS:
IS A SECOND UNIT AYES
SECOND STORY F]YES
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BEING ADDED? ANO
ADDITION? r-JNo
PRE -APPLICATION ❑ YES IF YES, PRO-%iflE COPY OF
PLANNING APPL N0 ' PLANLTLNCT RPPRO\ AL LETTER -
IS THE BLDG AN YES
EICHLER HOhSE. NO
RECEIVED S$` �
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TOTAL VALUATION:
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property oumer's behalf. I have read this
application and the information I have provided is correct..I have read the Description ofWork and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to
/.-� � Date:
SUPPLEMENTAL TKTFORMATION REQUIRED
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New SFD or Multifamily dvvellings: Apply for demolition permit for
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OSY-ER'THE-COUNTER
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existing building(s). Demolition permit is required prior to issuance ofbuilding
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permit for new building.
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_ Commercial Bldgs: Provide a completed Hazardous Materials DisclosureTANDX7tn
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form if any Hazardous Materials are being used as part of this project.
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_ Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
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BId,-App_2011.doc revised 06/21/11