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B-2018-1221 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1221 10495 S DE ANZA BLVD CUPERTINO,CA 95014-3011(359 17 023) ALEGIS CONSTRUCTION INC PORTLAND,OR 97223 OWNER'S NAME:Bile Atwater Shops Lp DATE ISSUED:07/25/2018 OWNER'S PHONE: PHONE NO:(206)7244385 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic,#9 6H Contractor ALEGIS CONSTRUCTION INC Date 10/31/2018 X BLDG ELECT_PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH_RESIDENTIAL X COMMERCIAL with Section 7000)of Division 3 of f is Business&Professions Code and that my license is in full farce and effect. JOB DESCRIPTION: FLEX COLLEGE PREP T.1.-(400 SF);DEMO(E)OFFICES;BUILD(N) I hereby affirm under penalty of perjury one of the following two declarations: NON-STRUCTURAL PARTITION WALL TO CREATE NEW OFFICE r. I have and will maintain a certificate of consent to self-insure for Worker's SPACE;EXTEND PARTITION TO ROOF IN OPEN OFFICE SPACE. Compensation,as provided for by Section 3700 of the Labor Code,for the .performance of the 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 Area: Valuation:$45000.00 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 slate laws relating to building construction,and hereby authorize 359 17 023 A(Tenant Improv menis),A(Tenant Iniprovements),A representatives of this city to enter upon the above mentioned property for (Tenant Impmvements),A(Tenant Improv ents),A Inspection purposes.(We)agree to save indemnify and keep harmless the (Tenant hnprovements),A(Tenant Improvements),A City of Cupertino against liabilities,judgments,costs,and expenses which (Tenant Improvements),A(Tenant Improvements),A may accrue against said City in consequence of the granting of this permit. (Tenant Improvements),A(Tenant Improvements),A Additionally,the applicant understands and will comply with all non-paint (Tenant Improvements) source regulations per It rtino Municipal Code,Section 9.18. Jignalure Data 0 7/2 512 01 8 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR QWNF.14;;;� )ECIARATIQN 180 DAYS FROM LAST CALLED INSPECTION. I hereby affirm that I am exempt Irom the Contractor's License Law far one of the following two reasons: Issued by:Jasmine Archbold t. 1,as owner of the property,or my employees with wages as their sole Date:07/25/2018 compensation,will do the work,and the structure is not intended at offered for sale(Sec.7044,Business&Professions Cade) RE-ROOFS: z. 1,as owner of the property,am exclusively contracting with licensed All roofs shall be inspected prior to any roofing material being installed.If a roof is contractors to construct the project(Sec.7044,Business&Professions Code), installed without first obtaining an inspection,I agree to remove all new materials for I hereby affirm under penalty of perjury one of the fallowing three declarations: insiWetian. r. I have and will maintain a Certificate of Consent to self-insure£or Worker's Compensation,as provided for by Section 3700 of the Label Code,for the Signature of Appli.ann performance of the work for which this permit is issued. Date:07/25/2018 z 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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER Permit is issued. 3. 1 certify that in the performance of the work for which this permit is issued,I HAZARDOUS MATERIALS DISCLOSURE shall not employ any person in any manner so as to become subject to the I hove read the hazardous materials requirements under Chapter 6.95 of the Worker's Compensation laws of California.If,after making this certificate,of California Health&Safety Code,Sections 25505,25533,and 25534.I will exemption,I become subject to the Worker's Compensation provisions of them aintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the Labor Code,I must forthwith comply with such previsions or this permit shall Health&Safety Code,Section 25532(a)should I store or handle hazardous be deemed revoked. material,Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I APPLICANT CEITP1FlCA'1-fON Will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I certify that I have read this application and state that the above information is the Health&Safety Code,S 'gns 25505,25533,and 25534. correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree Owner or authorized aa.. to save indemnify and keep harmless the City of Cupertino against liabilities, Data:07/25/2018 judgments,costa,and expenses which may accrue against said City in CONSTRUCTION LENDING AGENCY consequence of the granting of this permit.Additionally,the applicant understands I hereby affirm that there is a construction lending agency for the performance and will comply with all non-point source regulations per the Cupertino Municipal of work's for which this permit is issued(Sec.3097,Civ C.) Cade,Section 9.18. Lender's Name Lender's Address Signature Date 07/25/2018 ARCHITECT'S DECLARATION I understand my plans shall be used es public records.