B-2018-0446 CITY OF CUPERTINO BUILDING PERMIT
BU I LDINGADDRESS: CONTRACTOR: PERMIT NO:B-2018-0446
19419 STEVENS CREEK BLVD STE 150 CUPERTINO,CA 95014(316 20 112) 0 WNER/BUILDER
965 PAGE MILL RD
PALO ALTO,CA 94304-
1013
OWNER'S NAME:MAIN STREET CUPERTINO DATE ISSUED:05/25/2018
OWNER'S PHONE: PHONE NO:None
LICENSED CONTRACTOR'S BUILDING PERMIT INFO:
License Class Lic.#
Contractor OWNER/BUILDER Date X BLDG ELECT_PLUMB
1 hereby affirm that I am licensed under 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 toll force and effect. JOB DESCRIPTION:
1st FLOOR;T.I.-RETAIL SPACE-(468 SF)
1 hereby affirm under penalty of perjury one of the following two declarations:
r, I have and will surra n 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.
z. 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 Flom•Area: Valuation:532000.00
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 31620 112 A(Tenant[mprov ents),M(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 Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 5/2512018 Issued by:Abby Ayende
Date:05/25/2018
OWNER-BBILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law t'nr one of the RE-ROOFS:
following two reasons: All roofs shalt be inspected In to any roofing materiel being installed If a roof is
1. I,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
ompensation,will do the work,and the structure is not intended or offered for inspection,e\
.is
(Sce.7044,Business&Professions Code)
I,as owner ofthe property,anoexclusively contracting with licensed Signature ofAppliernt:
contractors to construct the project(Sec.7044,Business&Professions Cade). Darr.5125/2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO RE CLASS"A"Oil BETTER
r. 1 have and will maintain a Certificate of Consent to self-insure tar Worker's
Compensation,as provided for by Section 3700 of the Labor Cade,for the
/1 perfoomanee ofthe work£or which this permit is issued, HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements trader 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 mmoner so as to become subject to the material.Additionally,should I use equipment mdevices 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 complin nee with the Cupertino Motiedind Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505, 5533,aqd 25534,
Label Code,I Host forthwith comply with such provisions or this permit shall m _
APPLICANT CERTIFICATION Date:5/25/2018
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,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 ARCI11'I'I'sC'1'8 DECLARATION
Code,Section/9'./1118., 1 understand my plans shall be used as public records.
Signature / Date 5125!2018 Licensed
Professional