15060159 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: !PERMIT NO:15060159
10310 N FOOTHILL BLVD CUPERTINO CA 95014(326 15 096) D&B LEGACY LLC
10450 SERRA ST
CUPERTINO,CA 95014
.::OWNER'S NAME:
DATE ISSUED:07.28'2017
I
1OWNER'S PHONE:( PHONE NO:(408)234-4835
LICENSED CONTRACTOR'S DECLARATION iBUILDING PERMIT INFO•
License Class Lic.# I
;Contractor D d B LEGACY LLC Date i_BLDG _ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing — v1EC1!_RESIDENTIAL._COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. 1JOB DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations: 1CONSTRUCT(N)15 UNIT APARTMENT COMPLEX(14130 S.F)WITH
GROUND LEVEL GARAGE(4,560 S.F).
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
performance of the work for which this permit is issued.
2 I have and will maintain Worker's Compensation Insurance,as provided for by
i Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
,Sq.Ft Floor Area: ;Valuation:51700011000
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 iAPN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize i326 15 096
representatives of this city to enter upon the above mentioned property for
i inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which
;may accrue againstsai. City in consequence of the granting of this permit. PERF"IIT EXPIRES IF WORK IS NOT STARTED I
Additionally,the applica (understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
!source regulatie;s per e Cupertino Munici.al Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
i
y+ature Date ,Issued by:Kim Dunbar
Date:07/28/2017
OWNER-BUILDER DECLARATION
I hereby affirm that 1 ant exempt from the Contractor's License Law for one of the RE-ROOFS: j
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
m 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 stntcmre is not intended or offered for inspection.
sale(See.7044,Business&Professions Code)
f 2 ) I.as owner of the property,am exclusively contracting with licensed Signature of Applicant:
•/ contractors to construct the project(Scc.7044,Business&Professions Code). Date:
I hereby affirm under penalty of perjury one of the following three declarations:
t. 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
( 2 J I have and will maintain Worker's Compensation Insurance.us provided for by = 1 have read the hazardous materials requirements under Chapter 6.95 of the
i 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
2 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
material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner sn as to become subject to the
Worker's Compensation laws of California. If.alter making this certificate of air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cu it, 'no Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety
/ t 3 I
APPLICANT CERTIFICATION Date:
i 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
I Professional