B-2017-2028 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-2028
10805 N WOLFE RD STE 104 CUPERTINO,CA 95014(316 05 056) PATRICK 1 WILLIAMS
LAKE FOREST,CA
92630
OWNER'S NAME:CUPERTINO VILLAGE LP DATE ISSUED:04/23/2018
OWNER'S PHONE: PHONE NO:(949)859-0898
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class 8 Lie.#360 AZ
Contractor PATRICK J WILLIAMS Date 03/31/2019 X BLDG ELECT—PLUMB
1 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:
YOGA POD-T.I.;YOGA STUDIO(3095 ST.)I hereby affirm under penalty of perjury one of the fallowing two declarations:
n. 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[he
performance of the work for which this permit is issued.
z. I have and will maintain Worker's Compensation Insurence,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:,$475000.00
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 slate laws relating to building construction,and hereby authorize 316 05 056 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 WORT{IS NOT STARTED
may accrue against sal 61 in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the agpl cant r(deodands and will comply with all non-point
source reg/ul/at"I Ss per cup ino Municipal Co i,Section 9.18, 180 DAYS FROM LAST CALLED INSPECTION.
Signatury/ ale 04/23/2018 Issued by:Jasmine Archbold
t Date:04/23/2018
4W4
11-BUILDER DECLARATION
I hereby Amina that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected to to any roofing material being installed.If a roof is
t. 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(Scc.7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Sigumure of Applicant:
contractors to construct the project(See.7044,Business&Professions Code), Date:04/23/2018
1 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
z. I have and will maintain Worker's Compensation Insurance,as provided for by I have rend the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work to(which this California Health&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
a. 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
Io
shot[not em n material.Additionally,should 1 use equipment or devices which emit hazardous
employ any person i n any manner sous to become subject to the mr contumimm s as defined by the B.yArea Air Quality Management District 1
Worker's Compensation laws of California,If,aftermaking this certifloata of will mubmin compliance with the Cup�rSi nnieipsl Code,Chapter 9.12 and
exemption,)become subject to the Worker's Compensation provisions of the the Health&Safety Code, oft_
5533,and P534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agerjt.
APPLICANT CERTIFICATION Date:04/2312018
I certify that I have read this application and state that the above Information is CONSTRUCTION LENDING AGENCY
correct.1 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 ARC HITCCT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 04123/2018 Professional