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B-2018-1686CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2018-1686 10125 S DE ANZA BLVD CUPERTINO, CA 95014-2105 (359 09 017) DANNA BUILDERS CAMPBELL, CA 95008 OWNER'S NAME: Ponderosa Real Estate Associates DATE ISSUED: 10/09/2018 OWNER'S PHONE: PHONE NO: ( LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class b Lic. #891972 Contractor DANNA BUILDERS Date 03/31/2019 X BLDG _ELECT —PLUMB — MECH RESIDENTIAL X COMMERCIAL I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing — _ with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: CORNER STONE TITLE CO. T.I. - (2) RESTROOMS-(112 SF) I hereby affirm under penalty of perjury one of the following two declarations: 1. I have and will maintain a certificate of consent to self -insure for Worker's ' p Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 2. 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: $5000.00 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 359 09 017 A (Tenant Improvements),A (Tenant Improvements),A representatives of this city to enter upon the above mentioned property for (Tenant Improvements),A (Tenant Improvements),A inspection purposes. (We) agree to save indemnify and keep harmless the (Tenant Improvements),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 -point (Tenant Improvements) source reguAribiks Code, Section 9.18. PERMIT EXPIRES IF WORK IS NOT STARTED signature Date 140/18 WITHIN 180 DAYS OF PERMIT ISSUANCE OR OWNER -BUILDER DECLARATION 180 DAYS FROM LAST CALLED INSPECTION. 1 hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: Issued by: Haley McKee t. I, as owner of the property, or my employees with wages as their sole Date: 10/09/2018 compensation, will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) RE z. I, as owner of the property, am exclusively contracting with licensed -ROOFS: 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 following three declarations: inspection. t. 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 Signature of Applicant: performance of the work for which this permit is issued. Date: 10/9/18 2. 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 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER permit is issued. 3. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the HAZARDOUS MATERIALS DISCLOSURE I have 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 the maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Labor Code, I must forthwith comply with such provisions 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 CERTIFICATION 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 Cod , tions 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 agent: to save indemnify and keep harmless the City of Cupertino against liabilities, Date: 10/9/18 judgments, costs, 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.) Code, Section 9.18. Lender's Name Lenders Address Signature Date 10/9/18 ARCHITECT'S DECLARATION I understand my plans shall be used as public records.