B-2017-1143 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1143
10915 N WOLFE RD STE 102 CUPERTINO,CA 95014 0 to 05 056) GOLD MEDALLION
INC
WALNUT CREEK,CA
94596
OWNER'S NAME:CUPERTINO VILLAGE LP DATE ISSUED:03/07/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lie.#50M
Contractor GOLD MEDALLION INC Date 02/29/2020 X BLDG_ELECT_PLUMB
I hereby affirm that I am licensed tinder 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:
CREAMISTRY-T.I.-(1138 SF)
I hereby affirm under penalty of perjury one of the following two declarations: REV#1- I-HOUR RATED WALLS TO NON-RATED PARTITIONS
i. I have and will maintain a certificate o£consent to self-insure for Worker's WALL;CHANGE ARCHITECT OF RECORD-ISSUED 05-04-2018
Compensation,as pi ovided for by Section 3700 of the Labor Code,for the REV#2-STEEL FRAMING FOR ROOF TOP MECHANICAL UNIT-
perfcomane,of the work for which this permit is issued. ISSUED 06-01-2018
x. I have and will maintain Worker's Compensation Insurance,as provided for by
Grf„Section 3700 of the Labor Code,for the performance orthe work for which this
�f`� permit is issued. Sq.Ft Floor Arco: Valuation:$200000.00
APPLICANT CERTIFICATION
1 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 ANN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 316 05 056 A(Tenant Improvemcnts),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�MuInoe,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature - Date 06-01-2018 Issued by:Abby Avende
Date:03/07/2018
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.Ifo roof is
n. 1,as owner of the property,or my employees with wages as their sale 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 Cade)
x. 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:06-01-2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTERr. 1 have and will maintain a Certificate of Consent to self-[nerve 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
x. I have and will maintain Worker's Compensation Insurance,as provided for by 1 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. m aintain compliance with the Cupertino Munlclpal Code,Chapter 9.12 and the
a. I certify that in the performance o£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,alter 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 dna the Health&Safety Code,Sections 25505,25533,mid 25534,
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CKRT_IFICATION Date;06-01-2018
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,Clv 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 ARCHITECTS DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 06-01-2018 Licensed
Professional