B-2018-2046 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-2046
19766 STEVENS CREEK BLVD CUPERTINO,CA 95014(369 06 012) GIDEL&KOCAL
CONSTRUCTION CO
INC
CAMPBELL,CA 95008
OWNER'S NAME: DATE ISSUED:03/28/2019
OWNER'S PHONE: PHONE NO:(408)370-0280
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class GENERAL BUILDING CONTRACTOR Lic.#403050
Contractor GIDEL&KOCAL CONSTRUCTION CO INC Date 04/30/2019 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:
CUPERTINO FAMILY EYE CARE-T.I.(1,384 S.F.)
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
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
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:$130000.00
APPLICANT CERTIFICATION
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 06 012 A(Tenant Improvements),B(Tenant Improvements),B
representatives of this city to enter upon the above mentioned property for (Tenant Improvements),M(Tenant Improvements),A
inspection purposes. (We)agree to save indemnify and keep harmless the (Tenant Improvements),A(Tenant Improvements),A
City of Cupertin
Code,Section 9.18. (Tenant Improvements)
<�77 nature Date PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
OWNER-BUIL E LARATION 1.80 DAYS FROM LAST CALLED INSPECTION.
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. I,as owner of the property,or my employees with wages as their sole Issued by:Kim Dunbar
compensation,will do the work,and the structure is not intended or offered for Date:03/28/2019
sale(Sec.7044,Business&Professions Code)
2. 1,as owner of the property,am exclusively contracting with licensed RE-ROOFS:
contractors to construct the project(Sec.7044,Business&Professions Code). All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm under penalty of perjury one of the following three declarations:
installed without first obtaining an inspection,I agree to remove all new materials for 1. I have and will maintain a Certificate of Consent to self-insure for Worker's inspection.
Compensation,.as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. Signature of Applicant:
2. I have and will maintain Worker's Compensation Insurance,as provided for by Date:
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
3. I certify that in the performance of the work for which this pen-nit is issued,I
shall not employ any person in any manner so as to become subject to the HAZARDOUS MATERIALS DISCLOSURE
Worker's Compensation laws of California. If,after making this certificate of I have read the hazardous materials requirements under Chapter 6.95 of the
exemption,I become subject to the Worker's Compensation provisions of the California Health&Safety Code,Sections 25505,25533,and 25534. I will
Labor Code,I must forthwith comply with such provisions or this permit shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
be deemed revoked. Health&Safety Code,
of work's for which this permit is issued(Sec.3097, Civ C.)
Lender's Name
Date Lender's Address