B-2019-1060 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-106
20803 ALVES DR CUPERTm ,CCA 326 32 039
( ) EARL ADAMS TILE-
COPING
95014-1899 0
-
COPING&
PLASTERING INC
PLEASANTON,CA
94588
OWNER'S NAME: DATE ISSUED:06/18/2019
OWNER'S PHONE: PHONE NO:(925)828-3100
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C53 Lic.#726779
Contractor EARL ADAMS TILE-COPING&PLASTERING INC Date 08/31/2020 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:
I hereby affirm under penalty of perjury one of the following two declarations: YMCA-T.I.-POOL-(28,005 SF):RESURFACING ONLY-NO
1. I have and will maintain a certificate of consent to self-insure for Worker's CHANGE TO GUNITE STRUCTURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
/oerformance of the work for which this permit is issued.
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:
q Valuation.$52480.00
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 326 32 039 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 WOR
may accrue against said City in consequence of the granting of this permit. KIS NOT STARTED
Additionally,the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED
INSPECTION.
Signature
.,
Date 6-18-2019
Issued by..
Kim Dunbar
Date:06/18/2019
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.If a roof is
1. 1,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)
2. 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:6-18-2019
I hereby affirm under penalty of perjury one of the following three declarations:
1. I have and will maintain a Certificate of Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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
i. 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 Code,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,I 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
Worker's Compensation laws of California. If,after snaking this certificate of air contaminants as defined by the Bay Area Air Quality Management District I
exemption,I become subject to the Worker's Compensation provisions of the
will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
the Health&Safety Code,Sections 25505 25533 and 25
Labor Code,I must forthwith comply with such provisions or this permit shall 534.
be deemed revoked.
Owner or authorized agent.
APPLICANT CERTIFICATION Date:6-18-2019
I certify that I have read this application and state that the above information is CONSTRUCTION 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 ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 6-18-2019 Licensed