B-2018-0561 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0561
10787 S BLANEY AVE CUPERTINO,CA 95014-4500(369 34 053) AD&C DESIGN INC f
FREMONT,CA 94539
OWNER'S NAME:PACIFIC RIM PARK LLC DATE ISSUED:04/05/2018
OWNER'S PHONE: PHONE NO:(510)625-9566
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class!4 Lic.#929828
Contractor AD&C DESIGN INC Date 11/30/2019 X BLDG—ELECT—PLUMB
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:
TP TEA-INSTALL NEW CHANNEL LETTERS ON RACEWAY
I hereby affirm under penalty of perjury one of the following two declarations:
1. f 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 ofthe work for which this permit is issued.
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 Arca: Valuation:$5000.00
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 34 053
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 04-05-2018 Issued by:Kim Dunbar
Date:04/05/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Cour actor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.Its root'is
r. I,as owner cf the property,or my employees with wages as their sole installed without first obtaining an inspection,1 agree to remove all new materials for
compensation,will do the work,and the an t cture is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sce.7044,Business&Professions Code). Date:04-05-2018
I hereby affirm wider penalty of perjury site of the following three dodaratim s: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTERz. }have and will maintain a Certificate of Cousent 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 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.twill
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. 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 I use equipment or devices which emit hazardous
mr 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 the Cupertino Municipal Code,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
APPLICANT CERTIFICATION Date:04-05-2018
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 ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Data 04-05-2018
Professional