B-2016-3302 1
CITY OF CUPERTINO BUILDING PE1RMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3302
19000 HOMESTEAD RD UNIT 2 CUPERTINO,CA 95014-0712(316 09 036) KAISER FOUNDATICN
HEALTH PLAN INC
ANAHEIM,CA 92807
OWNER'S NAME: ARC KFCPTCA001 LLC DATE ISSUED:12/20/2016
OWNER'S PHONE:408-590-4756 1 PHONE NO:(714)572-7401
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class E Lic.#370871 X BLDG X ELEC _PLUMB
Contractor KAISER FOUNDATION HEALTH PLAN INC Date 03/31/2017
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:
UNIT 2-T.I.- REPLACE(75)LIGHT FIXTURES-KAISER
I hereby affirm under penalty of perjury one of the following two declarations: W Mk-NPD icik l u1�
1. I have and will maintain a certificate of consent to self-insure for Worker's f
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
o2.i
y
\.� Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$106542.00
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 316 09 036
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 against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the C : rti•• - iai Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
4
C-Signature/- A 0 Date 12/20/2016 Issued by:Abby Ayetide
Date: 12/20/2016
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 inspeetcd prior to any roofing material being installed.If a roof is
1. 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)
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:12/20/2016 1
I hereby affirm under penalty of perjury one of the following three declarations:' ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
i. 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. 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 Code,Sections 25505,25533,and 25534. I will
maintain compliance th the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued.
a. I certify that in the performance of the work for which this permit is issued,I Health&Safety Co e,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 so as to become subject to the 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 complian with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sectio, 255 i,:,25533 an 534.
Labor Code,I must forthwith comply with such provisions or this permit shall ���
be deemed revoked. Owner or authorized a Le it: . L il_r
APPLICANT CERTIFICATION `Date:12/20/2016 CONSTRUCTION LENDING AGENCYI 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 and state laws I hereby affirm that the a 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, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans Shall be used as public records.
Code,Section 9.18.
Licensed
Signature Date 12/20/2016 Professional