B-2016-2889CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-2889
20400 STEVENS CREEK BLVD CUPERTINO, CA 95014 (369 01 028)
CODYBROCK INC
SAN CARLOS, CA
94070
OWNER'S NAME: CUPERTINO CITY CENTER BUILDINGS
DATE ISSUED: 12/02/2016
OWNER'S PHONE: 408-873-0121
PHONE NO: (650) 591-0757
LICENSED D ONT A TOR' DECLARATION
BUILDING PERMIT INFO:
License Class $ Lic. #533971
Contractor CODY/BROOK INC Date 04/30/2018
X BLDG _ELECT _PLUMB
MECH RESIDENTIAL X COMMERCIAL
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.
JOB DESCRIPTION:
SUITE 400; 4TH FLOOR; T.I. - MEETING/BREAK ROOMS/LOBBY
I hereby affirm under penalty of perjury one of the following two declarations:
(19,648 S.F.)
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. .
f f I- 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
Sq. Ft Floor Area:
Valuation: $450000.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
369 Ol 028
369
B (Tenant Improvements)
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
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant understands and will comply with all non -point
source regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature :. Date [Z-4 1(
Issued by: Kim Dunbar
OWNER-BiRDERDECLARATION
Date: i2/02/2016
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RF. -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
1. I, as owner of the property, or my employees with wages as their sole
installed without first obtaining an inspection, I agree to remove all new materials for
compensation, will do the work, and the structure is not intended or offered for
inspection.
sale (Sec.7044, Business & Professions Code)
2. 1, as owner of the propert3, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Scc.7044, Business & Professions Code).
Date:
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have maintain Worker's Compensation Insurance, as provided for by
HAZARDOUS
I have read the hazardous materials requirements under Chapter 6.95 of the
2. and will
Section 3700 of the Labor Code, for the performance of the work for which this
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
3. 1 certify that in the performance of the work for which this permit is issued, I
material. Additionally, should I' use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If, after making this certificate of
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Section 255052 533rand 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
Owner or authorized agent:
APPLICANT CERTIFICATION
/ �P
Date: (,'r Z//�
I certify that I have read this application and state that the above information is
CONCTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant understands
ARCHITECT'S DECLARATION
and will comply with all non -point source regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date
Professional