B-2018-1243 CITY OF CUPERTINO BUILDING PERMIT
BE[LDINGADDRESS: CONTRACTOR: PERMIT'NOt B-2018-1243
23500 CRISTO REY DR CUPERTINO,CA 95014-6527(342 54 999) BAY AREA
ENTERPRISE
SAN JOSE,CA 95148
OWNER'S NAME:The Forum DATE ISSUED:08/01/2018
OWNER'S PHONE: PHONE NO:(408)238-5043
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
Llrense Class @ Lic.#817817
Contractor BAY AREA ENTERPRISE Dale03/31/2019 XBLDG_ELECT_PLUMB
I hereby affirm that I am licensed under the provlsimns of Chnpter 9(commencing MECH_RESIDENTIAL X COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect JOB DESCRIPTION:
CONSTRUCT(N)GARDEN ARBOR AT JAPANESE GARDEN
I hereby affirm under penalty of perjury one of the following two declarations:
r. I have and will maintain a certifieste of consent to self-insure for Worlror's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
6i. 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
.0 permit is issued. Sq.Ft Floor Area: Valuation:$2000.00
APPLICANT CERTIFICATION
I certify that I have read this application and slate that the above
information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 342 54 999 A(Tenant Improvements)
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save Indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITI-HN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature �- � ""Date 8�-2Q1.$ Issued by:Kim Dunbar
Date:N/O t/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
fallowing two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
n, 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
c
ompemsation,will do the work,and the structure is not intended or offered for inspection.
sale(Sm.7044,Business&Professions Code)
a. 1,as owner of the property,am exclusively contracting with licensed Signature ofApplicanc
contractors to construct the project(Sce.7044,Business&Professions Code). Date; -1�-2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL 1200E COVERINGS TO BE CLASS"A"OR BETTERn. I have and will maintain a Certificate of Consent to self-insure,for Worker's
Comjirensaliou,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
1. I have and will maintain Worker's Compensation Insuronce,as provided for by I have read the hazsu•dous materials requirements under Chapter 6.95 of the
Section 3700 of the Lohor Code,for the performance of the work for which this California Health&Safety Cade,Sections 25505,25533,and 25534.I will
permit is issued maintain compliance with the Cupertino Municipal Code,Chapter 9.12 red 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 1 store or handle hazardous
shall not employ any person in any manner so as to become subject to the material Additionally,should 1 use equipment or devices wile t mit hazardous
ah•—ustnrivants as defined by the Bay Are.Air Q duty nge
m
e
n
t Disn•ict I
Worker's Compensation laws of Cali rat air.IC,after making this certificate of will maintain compliance with the Cupert eo
Labor Code,I must forthwith comply with such provisions m this permit shall
be deemed revoked. Owner or authorized agent::
APPLICANT CEIi'I'IFICATION Date:B1-201.8
I certify that I have read this application and slate that the above information IS CONSTR[JCTfON 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 Date 8-1-2018
Professional