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B-2018-0560 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:&2018-0560 19160 STEVENS CREEK BLVD CUPERTINO,CA 95014(375 07 00t) STEVENS CREEK L P 1400 PARKMOOR AVE STE 190 SAN JOSE,CA 95126 OWNER'S NAME:STEVENS CREEK LP DATE ISSUED:04/05/2018 OWNER'S PHONE: PHONE NO:None LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic.# Contractor STEVENS CREEK LP Date X BLDG X ELECT—PLUMB 1 hereby affirm that 1 at licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL_COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: (N)TEMPORARY POWER POLE(200 AMPS) I hereby affirm under penalty of perjury one of the following two declarations: 1. 1 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. z. I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for Ore performance of the work for which this permit is issued. Sq.Ft Floor Area: 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 37507 001 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:Jasmine Archbold Date:04/05/2018 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of theRE-ROOFS: following two re anus All roofs shall be inspected prior to any roofing mine,is]being installed If. of is hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER i. 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. 1 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,and 25534.I will permit is issued. nutintain complhmce with the Cupertino Municipal Code,Chapter 9.12 nod the s. 1 certify that in the performance of the wok for which this permit is issued,I Health&Safety Code,Section 25532(a)should 1 store or handle hazardous shall not employ any person in any mannerso as to become subject to the materia.Additiunafly,should 1 use equipment or devices which emit hazardous air conhnminants as defined by the Bay Area it Qua t Management District I Worker's Compensation laws of California.If,after making this certificate of will maintaincompliance with the C it.. talc al ode,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety' Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: APPLICANT CERTIFICATION Date:04/05/2018 1 certify that I have read this application and state that the above Information Is CONSTRUCTI LEN G AGENCY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a consfIbotion 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"to ainst said City in Lender's Address consequenceof the grantin ofy,the applicant understandsandwillcomplywith all n ofr the Cupertino Municipal ARCIIITECT'S DECLARATION Code,Section 91 understand my plans shall be used as public records. - Licensed 04/05/2018 Professional