B-2018-1226 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1226
23500 CRISTO REY DR CUPERTINO,CA 95014-6527(342 54 999) CONOLEY ELECTRIC
SAN CARLOS,CA
94070
OWNER'S NAME:The Forum At Rancho San Antonio DATE ISSUED:07/26/2018
OWNER'S PHONE: PRONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-10 Llc.#839451 X BLDG X ELECT—PLUMB
Contractor CONOLEY ELECTRIC Date 0513112020 —
1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL—COMMERCIAL
with Section 7000)of Dfvisfon 3 of the Business&Professions Code and that my
license is in full force unit effect. JOB DESCRIPTION:
REMOVAL OF 4 EXISTING WASHING MACHINES;INSTALL 4 NEW
of the Labor Code,for the performance of the work for which this
permit is issued. Sq,Ft Flom-Arco: V.luation:$8500.00
APPLI('ANT CRRTTFTCATiON
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: Occupuncy Type:
and stale laws relating to building construction,and hereby authorize 342 54 999 A(Tenant Improvements)
representatives of this city to enter u e the above mentioned property for
inspection purposes. (We)agree sav indemnify and keep harmless the
City of Cupertino against Iiabilitl judg ants,costs,and expenses which PERMIT EXPIRES IF WORT{IS NOT STARTED
may accrue
code,section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 07/26/2018 Issued by:Jasmine Archbold
Date:07/26/2018
OWNERBUILDERDECLARATION
I hereby affirm that I am exempt from the Contractor's License Lav for ane of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If.roof is
t. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,l agree to remove all new materials for
ompensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
z I,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec.7044,Business&Professions Code). Dote:07/26/2018
I hereby affirm under penalty of perjury one or the yellowing three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
L I have and will maintain a Certificate of Consent m self-insure for Workers
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance orbit,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 Calfl'ornha Health&Safety Code,Sections 25505,25533,and 25534,1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9,12 and the
s. 1 certify dual in the perfonionce of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store ar Ir�rit a i".ardous
shall not employ any person in any manner so as m become subject to the material,Additionally,should 1 use equipment or devices Zl emit mzardnns
air contaminants us define�iy tJto-13 -rex Air Quali nngem it District 1
Worker's Compensation laws ofCalifornia,If,after making this certificate of wig maintain compliance n h CI pier 9.12 and
exemption,I became subject to the Worker's Compeusa[iou provisions oftheth5Labor Code,I must forthwith comply with such provisions or this permit shall
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 ARCHITCCT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
SignatureLicensed
Date 0712612018
Professional