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