B-2018-0685 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS; CONTRACTOR: PERMIT NO:B-2018-0685
10891 S BLANEY AVE CUPERTINO,CA 95014(369 34 052) PACIFIC RIM PARK
LLC
5057 FOREST GLEN
DR SAN JOSE,CA
95129-2110
OWNER'S NAME: DATE ISSUED:04/30/2018
OWNER'S PHONE: PHONE NO:None
LICENSED CONTRAC1OR'S DECLARATION BUILDING PERMIT INFO:
License Class Lie.#
Contractor PACIFIC RIM PARK LLC Date X04/30/2018 BLDG_ELECT_PLUMB
1 herebyform that I am licensed under the provisions of Cha ter 9(commencing —MECH—RESIDENTIAL X COMMERCIAL
n provi p (con g
with Section 7000)of Division 3 ofthe Business&Professions Cade and that my
license is in fall force and effect. JOB DESCRIPTION:
HARVARD SQUARE 2-T.I.CHANGE OUT DOUBLE IN-SWINGING
I hereby affirm under penalty of perjury one ofthe following two declarations: DOORS TO SINGLE OUT-SWINGING DOOR AT REAR EXIT;(N)36"
n. I have and will maintain a certificate of eensent to self-insure for Worker's GUARDRAIL AT REAR
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
z. I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 ofthe Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Arca; 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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 369 34 052 A(Teuam 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.
Signature Date Issued by:Jasmine Archbold
Date:04/30/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
fulloring two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
n. 1,as owner ofthe 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 Cade)
z. 1,ascaner ofthe property,am exclusively contracting with licensed Signature of Applicant:
contract—to construct the pr ject(Sec.7044,Business&Professions Cade). Date:
1 hereby affirm under penalty of perjury one ofthe fallowing three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. I have and will maintain a Certificate of Consent to se1f4ason 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
z. I have and will maintain Wo ken's Compensation Insurance,as provided£or by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the perfomrance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.f will
permit is issued. maintain compllarou with the Cupertino Municipal Code,Chapter 9.12 and the
s. I certify that m the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should 1 stare 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 Cali£ornin.If,ager making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,l become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner orIf rized ag
APPLICANT CERTIFICATION Date: 3p 1'p
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 Inspectlon 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 ARCHITE'CT'S DECLARATION
Cade,Section 9.18. understand my plans shall he used as public records.
Sig atur1 Date /�7'0'�0 Licensed
CITY OF CUPERTINO BUILDING PERMIT
BE ILDINC ADDRESS: CONTRACTOR: PERMIT NO;B-2018-0685
10891 S BLANEY AVE CUPERTINO,CA 95014(369 34 052) PACIFIC RIM PARK
LLC
5057 FOREST GLEN
DR SAN JOSE,CA
95129-2110
OWNER'S NAME: DATE ISSUED:04/30/2018
OWNER'S PHONE: PHONE NO:None
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor PACIFIC RIM PARK LLC Date X BLDG—ELECT—PLUMB
I hereby affirm that I um licensed under the provisions of Chapter 9(commeneing —MECH—RESIDENTIAL 2CC COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force snit effect. - JOB DESCRIPTION:
HARVARD SQUARE 2-T.I.CHANGE OUT DOUBLE IN-SWINGING
I hereby affirm under penalty of perjury one of the following two declarations: DOORS TO SINGLE OUT-SWINGING DOOR AT REAR EXIT;(N)36"
a I hove mut will maintain a certificate ofeensent to self-insure for Worker's GUARDRAILAT REAR
Compensation,as provided for by Section 3700 of the Labor Code,for the REV#1-ADD DRAEJ PER INSPECTOR'S CORRECTION NOTICE —
peiformance o£the work for which this permit is issued, lb -ol (b 1201b
a I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance o£the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$1000.00
APPLICANT CEf2TIRICATION
I certify that I have read this applicatlon 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 34 052 A(Tenant Improvements)
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save Indemnlfy 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.
Signature Date 08-06-2018 Issued by:Jasmine Archbold
Date:04/30/2018
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 root's shall be inspected prior to any roofing material being installed.If e roof is
t. 1,as owner of the property,o my employee 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)
C 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contrucmrs to construct the project(Sec.7044,Business&Professions Code), Date:08-06-2018
I hereby affirm under penalty of perjury one of the following three declarations; ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
a. 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
e 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,said 25534.1 will
permit is issued, maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
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
C. 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
•contaminants as defined by the Bay Arca Ali-Quality Management District I
Worke's Compensation laws of California.If,after making thio certificate oP wI,maintain compliance with the Cupertino Municipal Codc,Chapter 9,12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized
APPLICANT CERTIFICATION Date:08-06-2018
correct.I agree to comply with all city and county ordinances and slate 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 ARCHI'TECT'S DECLARATION
Coda,
Date 08-06-2016 Licensed