B-2017-0132 CITY OF CUPERTINO BUILDING PERMIT
BUIELDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0132
22961 STEVENS CREEK BLVD,CUPERTINO,CA 95014 GRANITE
CONSTRUCTION
COMPANY
WATSONVILLE,CA
95077-5085
OWNER'S NAME: CUPERTINO HISTORIC SOCIETY DATE ISSUED:01/2512017
OWNER'S PHONE:408-973-1495 PHONE NO:(831)724-1011
LICENSED CONTRACTOR'S DECLARATION BUIULDING PERMIT INFO:
License Class CONSTRUCTION ZONE TRAFFIC CONTROL Uc.#U
Contractor GRANITE CONSTRUCTION COMPANY Date 05/31/2017 X BLDG X ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH_RESIDENTIAL X COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations: (N)TEMPORARY POWER POLE(200 AMP)
1, 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.
1 have and will maintain Worker's Compensation Insurance,as provided for by
tion 3700 of the Labor Code,for the performance of the work for which this
e*
permit is issued.ps: Sq.Ft Floor Area: Valuation:$1000.00
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 "N Number: Occupancy Type:
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.
Additionally,the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 112512017
Issued by:Abby Ay—ende
Date:01125/2017
OWNER--BUILDER DECLAR/1TION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS-
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. L as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all now 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 property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:1/25/2017
I hereby affirm under penalty of perjury one of the following three declarations:
t. 1 have and will maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS"All OR BETTER
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. T certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
Worker's Compensation laws of California. If,after making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I
exemption,I become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
e Health&Safety Code,Sections 25505,25533,and 25534.
h
Labor Code,I must forthwith comply with such provisions or this permit shall _*
be deemed revoked.
,Owner or authorized agent,
APPLICANT CERTIFICATION '- Date:11251201
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of tfiis city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino MunicipalARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 112512017 Licensed
GENERAL PERMIT APPLICATION 'B9016-0139- M E P
COMMUNITY DEVELOPMENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE- CUPER T IND,CA 95014-3255 AIM%L
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BULDNO: T7 COV'NeRCI-AL -1JRBkN NITERFACE AREA [3 "'0 FLOOD ZONE ❑2"0 TEICHLERHOME? Q NO
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TOTAL VALUATION: 0 c'
By my signature below,I certiry to each of the following: I am the property owner or authorized agent to act on the pioprert-,,owner*s behalf. I have read this
application and the information I have provided is coiTect I have read the Description of'W'ork-and verifV it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction. I authorize representatives of Cupend-no to enter the above-identified property for inspection purposes.
si-amature of."DplicanVAe-ent: Date:
SUPPLEI�IENTTAL NNFORMATIONT REQUIRED
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