B-2018-1337 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:13-2018-1337
5 RESULTS WAY CUPERTINO,CA 95014(357 20 042) SHAH&ASSOCIATES
INC
POWAY,CA 92064
OWNER'S NAME: DATE ISSUED:01/24/2019
OWNER'S PHONE: PHONE NO:(858)668-2828
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class a Lie.#920446
Contractor SHAH&ASSOCIATES INC Date 02/28/2019 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 the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
AT&T-CELL MODIFICATION-REMOVE AND REPLACE(3)
I hereby affirm under penalty of perjury one of the following two declarations: ANTENNAS;REMOVE AND REPLACE(6)RRU'S;INSTALL(3)NEW
i. I have and will maintain a certificate of consent to self'-insure for Worker's RRU'S;REMOVE AND REPLACE EQUIPMENT WITHIN EXISTING
Compensation,as provided for by Section 3700 of the Labor Code,for the SHELTER.
performance of the work for which this permit is issued.
/, !
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 357 20 042 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 the apt said City in consequence the comply
ing this permit.
intWITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands.and will comply with all non-point
source regulations per the Cgino Municipal Code,Section 9,18. 180 DAYS FROM LAST CALLED INSPECTION.
Sign- Date 01/24/2019 Issued by:Jasmine Archbold
Date:01/24/2019
OWNER-BUILDER DEC '• ' ON
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.If a roof is
i. I,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
compensation,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), Date:01/24/2019
•
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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
2. I 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 California Health&Safety Cade,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,l Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Munici,,,,.. Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety
�
APPLICANT CERTIFICATION Date:01/24/2019 `
I certify that I have read this application and state that the above information is COS i .CTION LENDINGNCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lendi g 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. I understand my plans shall be used as public records,
° Licensed
Signature Date 01/24/2019 Professional