B-2017-0943 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0943
20130 STEVENS CREEK BLVD 20130 CUPERTINO,CA 95014(369 56 001) G1DEL&KOCAL
CONSTRUCTION CO
INC
CAMPBELL,CA 95008
OWNER'S NAME: CUPERTINO ADOBE LLC DATE ISSUED:09/15/2017
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#403050
Contractor GIDEL&KOCAL CONSTRUCTION CO INC Date 04/30/2019 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:
CUPERTINO FAMILY EYE CARE-T.I.RETAIL(1560 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations:
i. 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.
!3.p 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. Sq.Ft Floor Area: Valuation:$135000.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 369 56 001 A(Tenant Improvements),B(Tenant Improvements)
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.
ipprSignature Date 9.15.17 Issued by:SEAN HATCH
Date:09/15/2017
OWNER-BUILDER DECLARATION
i
Thereby affirm that I;arn exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: I. All roofs shall be inspected prior to any roofing material being installed.If a roof is
i. 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
coriipensation,!willdo the work,and the structure is not intended or offered for inspection.
sale(See:7044;Business&;'Professions Code)
2. I,asowner of theproperiy,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:9,15.17
I hereby affirm'under,penaltyof 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
performance of the work.for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I 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 3.700 Of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify'that in the performance of the work for which this permit is issued,I Health 8c Safety Code,Section 25532(a)should I store or handle hazardous
material. Additionally,should I use equipment or devices which emit hazardous
shall not employ anypeson 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 CO to' hapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 2 �•l- and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall ®
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:9.15.17
I certify that I have read this application and state that the above information is CONSTRUCTION
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 this 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 Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. ' I understand my plans shall be used as public records.
Signature I Date 9.15.17 Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0943
20130 STEVENS CREEK BLVD 20130 CUPERTINO,CA 95014(369 56 001) GIDEL&KOCAL
CONSTRUCTION CO
INC
CAMPBELL,CA 95008
OWNER'S NAME:CUPERTINO ADOBE LLC DA'L'E ISSUED:09/15/2017
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class)3 Lic.#403050
Contractor GIDEL&KOCAL CONSTRUCTION CO INC Date 04/30/2019 X BLDG—ELECT—PLUMB
I hereby aITirm 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:
CUPERTINO FAMILY EYE CARE-T,I.RETAIL(1560 S,F.)
I hereby affirm under penalty of perjury one of fire Following two declarations:
I. I have and will maintain a certificate of consent to self-insure for Worker's REV#1-REVISE SCOPE OF WORK TO CANCEL TL AND RETURN
Compensation,as provided for by Section 3700 of the Labor Code,for the SUITES 20130&20132 TO ORIGINAL CONFIGURATION-ISSUED 6-
performance of the work for which this permit is issued. 27-2018
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 Sq,Ft Floor Area: Valuation:$135000.00
' 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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 36956 001 A(Tenant Improvements),B(Tenant Improvements)
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 1S 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 M Lnicpal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 6-12-2018 Issued by:SEAN HATCH
Date:09/15/2017
OWNER-BUILDER DECLARATION
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
r. 1,re 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 wok,and the structure is not intended or offered for inspection.
sal.(Sec.7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature ofApplicanr.
contractors to construct the project(Sec.7044,Business&Professions Code). Date:6-12-2019
I hereby affirm under penalty of perjury one of fire following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 o£the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I 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 ofthe Labor Code,for the performance of the work for which this California health&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued maintain compllonee with tire Cupertino Municipal Code,Chapter 9.12 and the
a. I certify that in the performance of the work for which this not is issued,1 Health&Safety Code,Section 25532(x)should I stare m•handle hazardous
shall not employ an nner se as to become subject to the material.Additionally,should I use equipment o'devices which emit hazardous
p y y person in any ma J air cnotaminants as dented by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of will mnlntain wmpliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I became subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 2;5534,
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:6-12-2018
I certify that I have read this application and slate 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 this city Of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned.properly for inspection purposes. (We)agree Lender's Name
to save indemnifyand 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 Municipal ARCHIT'ECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
SignatureLicensed
Data 6-12-2018
Professional