B-2017-0769 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0769
21731 STEVENS CREEK BLVD CUPERTINO,CA 95014-1119(326 20 048) WELLS
CONSTRUCTION INC
ROSEVILLE,CA 95678
•
OWNER'S NAME: FREELAND URI AND BATIA TRUSTEE DATE ISSUED: 10/11/2017
•
OWNER'S PHONE:650-823-4543 PHONE NO:(916)788-4480
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class)3 Lic.#619655 ,
Contractor WELLS CONSTRUCTION INC Date 05/31/2019 X BLDG _ELECT _PLUMB
MECH_RESIDENTIAL X COMMERCIAL
1 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 forceand effect. JOB DESCRIPTION:
STARBUCKS-T.I.(2383 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations: REV#1-PROVIDE ADDITIONAL SHEETS FOR CLARIFICATION-
1. I,have and will maintain a certificate of consent to self-insure for Worker's ISSUED 10/19/2017
Compensation,as provided for by Section 3700 of the Labor Code,for the •
. rformance of the work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance,as provided for byIF jopeSection 3700 of the Labor Code,for theperformance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:,$200000.00
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 326 20 060 A(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,th CupertinoMunicipal Code,Section 9.18; 180 DAYS FROM LAST CALLED INSPECTION.
T / Date 10/18/2017 Issued by:Jasmine Archbold
d. Date: 10/11/2017
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
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. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date: 10/18/2017 •
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
t. 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 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
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&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
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,Sections 5505, .- 3,and 25. 4.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked.
• Ow„ ,•rauthorized a•-• :
APPLICANT CERTIFICATION tln .10/18/2017
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 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.
Licensed
Signature Date 10/18/2017 Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-0769
21731 STEVENS CREEK BLVD CUPERTINO,CA 95014-1119(326 20 048) WELLS
CONSTRUCTION INC
ROSEVILLE,CA 95678 '
OWNER'S NAME: FREELAND URI AND BATIA TRUSTEE DATE ISSUED: 10/11/2017
OWNER'S I PHONE:650-823-4543 PHONE NO:(916)788-4480
•
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class 9:A Lic.#619655
Contractor WELLS CONSTRUCTION INC Date 05/31/2019 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:
STARBUCKS T.I.(2383 S.F.)
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
Compensation,as provided for by Section 3700 of the Labor Code,for the
erformance of the work for which this permit is issued.
,:ve and will maintain Worker's Compensation Insurance,as provided for by
AVction 3700 of the Labor Code,for the performance of the work for which this .
I! permit is issued. Sq.Ft Floor Area: Valuation:$200000.00
APPLICANT CERTIFICATION •
I certify that I have read this application and state that the above
informatibri'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 326 20 060 A(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 r9.61'ations,per th- Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
► 4 : Date 10/11/2017 Issued by:Jasmine Archbold
Date: 10/11/2017
.j
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. ,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. -I,;as owner Of the property,am exclusively contracting with licensed• Signature of Applicant:
contractorsto construct the project(Sec.7044,Business&Professions'Code). Date:10/11/2017
•
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-ihsure 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'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
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. I'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
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,Sections 25505,2. 33,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
'be deemed revoked.
Owner or aut,on d agent:
APPLICANT CERTIFICATION Date: a -aa;
low
I certify that I-,have read this application and state that the above information is '411na►- . 10 ►I_W I► ' E V
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 9.1'8. I understand my plans shall be used as public records.
Licensed
Signature ' Date 10/11/2017 Professional