B-2017-2046 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-2046
19540 VALLCO PKWY STE 100 CUPERTINO,CA 95014(316 20 119) PKC CONSTRUCTION
CO
LENEXA,KS 66214
OWNERS NAME:MAIN STREET CUPERTINO RETAIL PROPERTY LLC DATE ISSUED:03/28/2018
OWNER'S PHONE: PHONE NO:(
LENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class 5 Lic.#915118
Contractor PKC CONSTRUCTION CO Date 05131/2 01 8 X BLDG ELECT—PLUMB
I hereby affirm that I am licensed under the provisions xf Chapter 9(commencing —MECF4_RESIDENTIAL X COMMERCIAL
with Section 7000)of Division 3 a]the Business&Professions Code and that my
license is In fall force and effect. JOB DESCRIPTION:
BISHOPS CUTS&COLORS T.I.(946 SF)
I hereby affirm under penalty ofperjury one of the following two declinations:
r. I have and will maintain a certificate of consent to self-insum for Worker's
Compensation,as provided for by Section 3700 of the Labor Cade,for the
performance of the work for which this permit is issued.
1 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 Area: Valuation:$100000.00
APPLICANT CF.RTiFiCATION
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 stale laws relating to building construction,and hereby authorize 316 20 119 B(Tenant improvements)
representatives of this city to enter upon the above mentioned property for
Inspecllon 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 03/28/2018 Issued by:Jasmine Archbold
Date:03/28/2018
OWNER- L RAT
I hereby affirm that I aro exempt fir r the Contractor's License Law for one of theRE-ROOFS•
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
r. 1,as owner ofthe 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,mud the structure is not intended ca offered for inspection.
sale(Sec.7044,Business&Professions Code)
z. I,as owner of the property,am exclusively contracting with licensed Signature ofApplicaut:
contractors to construct the project(Sec,7044,Business&Professions Code). Date;03/28/2018
I hereby affirm under penulty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. I have and will maintain a Certificate of Consem to self-instue 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 n.atudals requirements order 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
a. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I stare or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,sluutd I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Arca 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,Chapt 9.12 and
exemption,l become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 2 505,2553 rd 255 4.
Labor Cade,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:0 3/2 812 01 8
I certify that I have read this application and state that the above Information is CON
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending age y 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.
Signature Date 0 312 8/2 01 8 Licensed
Professional