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B-2018-0211 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR; PCRMIT NO:B-2018-0211 10055 MILLER AVE STE 102 CUPERTINO,CA 95014-3468(369 06 011) OWNER/BUILDER OWNER'S NAME:LEE FUJIMOTO LO&ASSOCS LLC DA'Z'E ISSUED:07/19/2018 OWNER'S PHONE: PRONE NO;OWNER BUILDER LICENSED TRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic.If Contractor OWNER/BUILDER Date X BLDG_ELECT_PLUMB I hereby nl'lirm that[am licensed under the provisions of Chapter 9(commencing MECH_RESIDENTIAL X COMMERCIAL with Section 7000)or Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: LO DENTAL CARE-T.1-(1240 SF) I hereby affirm under penalty nl'perjury one of Lite following two declarations: r. 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 Jet formance of the work for which this permit is issued. z. I have and will maintain Worker's Compensation Insurance,as In far by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Flaor Area; Valuation:$90000.00 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 369 06 011 A(Tenant Improvenieots),B('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. 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 07/19/2018 Issued by:Jasmine Archbold Date:07/19/2018 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law,for one of the RE-ROOFS following two reasons: All roofs shall be inspected prior to any roofing material being installed.Ifo moria r. I,as owner of the property,army employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for cmnpenta tion,will do the work,and the structure is not intended or offered for inspection. sale(Sec.7044,Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed Signature ofAriplicmn: contractors to construct the project(Sec,7044,Business&Professions Cade), Date:07/19/2018 1 hereby affirm under penalty of perjury one of the yellowing three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER r. 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. HAZARDOUS MATERIALS DISCLOSURE z. I have and will maintain Worker's Compensation Insurzncc,as provided for by I have read the hazardous nmterials requirements under Chapter 6.95 of the Section 3700 of the Labor Code,for the performance of the wink 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 s. 1 certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store at handle hazardous shall not employ a material.Additionally,should I use equipment or devices which emit hazardous p y a y person in any manner so as to become subject to the air—taminants as defined by the Bay Aron Air Quality Management District 1 Worker's Cempeusntion laws of California,If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall �__� .,..ApII be deemed revoked Owner or authorized - APPLICANT CERTIFICATION Date:07/1912018 1 certify that I have read this application and state that the above information isCONSTRUCTION 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 1RCITM'S DECLARATION Code,Section 9.18. 1 understand my plans shall be used as public records. Lice sed Signature � Date 0 711 912 0 1 8 professional