B-2017-1985 CITY OF CUPERTINO BUILDING PERMIT
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BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1985
10741 N WOLFE RD CUPERTINO,CA 95014-0613(316 45 015) L THERMA LLC
SAN JOSE,CA 95133
OWNER'S NAME: QUITO HOSPITALITY ASSCS LLC ETAL DATE ISSUED: 11/30/2017 '
OWNER'S PHONE: PHONE NO:(408)347-3400
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C--10,C-4:C-20.C-36 Lic.#1027316 X BLDG _ELECT _PLUMB
Contractor THERMA LLC Date 05/31/2019
X 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:
HILTON GARDEN INN-REPLACE 100 TON CHILLER(LIKE FOR
I hereby affirm under penalty of perjury one of the following two declarations: LIKE)-ROOF TOP
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
) 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:$179000.00
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 316 45 015 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 aue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additi n Ily,the applicant understands and will comply with all non-point
sourc.
. Date 11/30/2017 Issued by:Jasmine Archbold
1 , v\&L_L-C- Date: 11/30/2017
OWNER-BUILDER DECLARATION .
I hereby affirm that ant 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
compenation,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: 11/30/2017
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. 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.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[use equipment or devices which emit hazardous
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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 t Cupertino Munici..al Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety a e,Sect'ons 2550. 533,and 25534.
Labor Cede,I must forthwith comply with such provisions or this permit shall
be deemed revoked. o
t•r authorized agent:
APPLICANT CERTIFICATION f5"• ' 11/30/2017
I certify that I have read this application and state that the above information is CONSTRUCTION LE 1ING AGENCY
correct.F agree tb'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 11/30/2017 Professional