B-2017-1267CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2017-1267
20813 STEVENS CREEK BLVD STE 250 CUPERTINO, CA 95014 (326 32 052)
GIDEL & KOCAL
CONSTRUCTION CO
INC
CAMPBELL, CA 95008
OWNER'S NAME: STEVENS CREEK OFFICE CENTERASSOCITATES
DATE ISSUED: 08/02/2017
OWNER'S PHONE: 408-855-9801
PHONE NO: (408) 370-0280
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class a Lic. #403050
Contractor GIDEL & KOCAL CONSTRUCTION CO INC Date 04/30/2019
X BLDG _ELECT —PLUMB
—
RESIDENTL4,L X COMMERCIAL
I hereby affirm rm that I am licensed under the provisions of Chapter 9 (commencing
— — —
with Section 7000) of Division 3 of the Business & ProfessionsCode and that my
license is in full force and effect.
JOB DESCRIPTION:
SCHWAKI- T.I. - OFFICE (3125 SF)
I hereby affirm under penalty of perjury one of the following two declarations:
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
rformance of the work for which; this permit is issued.
e and,will maintain Worker's Compensation Insurance, as provided for by
ction 3700 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area:
Valuation: $225000.00
,)O�a,
permitis issued.
APPLICANT CERTIFICATJON
I certify that I have'read this application and state that the above
APN Number:
Occupancy Type:
information is correct: I agree to comply with all city and county ordinances
326 32 052
B (Tenant Improvements)
and state laws relating to building construction, and hereby authorize
representatives' of,this city to enter upon the above mentioned property for
inspection purpose's. ;:(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 con equence of the granting of this permit.
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally, the applicant underst ds and'will comply with all non -point
source regulations per Cup the Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
SiA tiff te 8/212017
Issued b JASMINE ARCHBOLD
`DER
Date: 08/0/0 2/2017
OWNER- DE ARATI
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
t. I, as .owncr 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 (Sec7044, Business & Professions Code)
2. I, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to. construct the project(See.7044, Business & Professions Code).
Date: 8/2/2017
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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.
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
permit is issued. I
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 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 Municipal Code, Chapter 9,12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 25/133,d 25534.
Labor Code; I must forthwith comply with such provisions or this permit shall
be deemed revoked.Vt
orized agent:APPLICANT
CERTIFICATION
2017
I certify that I have read this application and state that the above information isTR
TI ENDING 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.
Licensed
Signature ! Date 8/2/2017
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1267
20813 STEVENS CREEK BLVD STE 250 CUPERTINO,CA 95014(326 32 052) GIDEL&KOCAL
CONSTRUCTION CO
INC
CAMPBELL,CA 95008
OWNER'S NAME: STEVENS CREEK OFFICE CENTER ASSOCITATES DATE ISSUED:08/02/2017
OWNER'S PHONE:408-855-9501 PHONE NO:(408)370-0280
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class j3 Lic.4403050
Contractor GIDEL&KOCAL CONSTRUCTION CO INC Date 04/30/2019 X BLDG _ELECT _PLUMB
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:
SCHWAK!-T.I.-OFFICE(3125 SF)
I hereby affirm under penalty of perjury one of the following two declarations: REV#1 MISC REVISIONS REFER TO NARRATIVE 1 AND
1. I have and will maintain a certificate of consent to self-insure for Worker's NARRATIVE 2-ISSUED 9/13/2017
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
ill 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:$225000.00
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 32 052 A(Tenant Improvements),B(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 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 Cupertino'Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
S.,•1 r c.1s a 4,1 1de - Date 9/13/2017 Issued by:SEAN HATCH,
Date:08/02/2017
OWNE UILDER 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 roofmg 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)
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:9/13/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. 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
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
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 Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25 33,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. - j
Owner or au-r, 'd agent: �. � ,�` 4��'
APPLICANT CERTIFICATION Date:9 ,,,e24
I certify that I have read this application and state that the above information is CONST TION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is 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. I understand my plans shall be used as public records.
Licensed
Signature Date 9/13/2017 Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1267
20813 STEVENS CREEK BLVD STE 250 CUPERTINO,CA 95014(326 32 052) GIDEL&KOCAL
CONSTRUCTION CO
INC
CAMPBELL,CA 95008
OWNER'S NAME: STEVENS CREEKOFFICE CENTER ASSOCITATES DATE ISSUED:08/02/2017
OWNER'S PHONE:408-855-9807 PHONE NO:(408)370-0280
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO•
License Class a Lic.#403050
Contractor GIDEL&KOCAL CONSTRUCTION CO INC Date 04/30/2019 X BLDG _ELECT _PLUMB
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
SCHAWK!-T.I.-OFFICE(3125 SF)
I hereby affirm under penalty of perjury one of the following two declarations: DEFERRAL#1-INSTALL CARD READER/PARTIAL DEMOLITION
i. I have and will maintain a certificate of consent to self-insure for Worker's OF EXISTING NON-STRUCTURAL PARTITIONS/REMOVAL OF
Compensation,as provided for by Section 3700 of the Labor Code,for the FLOOR FINISHES/CONSTRUCTION OF NEW INTERIOR
"71performance of the work for which this permit is issued. PARTITIONS/(N)FLOOR AND WALL FINISHES(N)LIGHT
2!„<"I have and will maintain Worker's Compensation Insurance,as provided for by FIXTURES(N)CONTROLS-ISSUED 12/13/2017
C''d Section 3700 of the Labor Code,for the performance of the work for which this REV#2 REVISE WALL TYPE FOR BATHROOMS-ISSUED 10-12-
permit is issued. 2017
APPLICANT CERTIFICATION REV#1 MISC REVISIONS REFER TO NARRATIVE 1 AND
I certify that I have read this applicatioh and state that the above NARRATIVE 2-ISSUED 9/13/2017
information is correct.I agree to comply with all city and county ordinances Sq.Ft Floor Area. Valuation:$225000.00
and state laws relating to building construction,and hereby authorize
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the APN Number Occupancy Type:
City of Cupertino against liabilities,judgments,costs,and expenses which 326 32 052 A(Tenant Improvements),B(Tenant Improvements)
may accrue against said City in consequence of the granting of this permit.
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cu ertino Municipal Code,Section 9.18.
PERMIT EXPIRES IF WORK IS NOT STARTED
"2 % /J WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Signature �..7 C.,& r+i�' / l 1/1
Date 12/13/2017
:� 180 DAYS FROM LAST CALLED INSPECTION.
OWNER--BUIL
U/ DER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the Issued by SEAN HATCH
following two reasons: Date:08/02/2017
1. I,as owner of the property,or my employees with wages as their sole
compensation,will do the work,and the structure is not intended or offered for RE-ROOFS:
sale(Sec.7044,Business&Professions Code) All roofs shall be inspected prior to any roofing material being installed.If a roof is
2. I,as owner of the property,am exclusively contracting with licensed installed without first obtaining an inspection,I agree to remove all new materials for
contractors to construct the project(Sec.7044,Business&Professions Code). inspection.
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 Signature of Applicant:
Compensation,as provided for by Section 3700 of the Labor Code,for the Date:12/13/2017
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance,as provided for by ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. HAZARDOUS MATERIALS DISCLOSURE
3. I certify that in the performance of the work for which this permit is issued,I I have read the hazardous materials requirements under Chapter 6.95 of the
shall not employ any person in any manner so as to become subject to the California Health&Safety Code,Sections 25505,25533,and 25534. I will
Worker's Compensation laws of California. If,after making this certificate of maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
exemption,I become subject to the Worker's Compensation provisions of the Health&Safety Code,Section 25532(a)should I store or handle hazardous
Labor Code,I must forthwith comply with such provisions or this permit shall material. Additionally,should I use equipment or devices which emit hazardous
be deemed revoked. air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
APPLICANT CERTIFICATION the Health&Safety Code,Sections 25505,25533 and 25534.
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 and state laws Owner-or authorized agent: -476Y-41/
relating to building construction,and hereby authorize representatives of this city Date:12/13/2017 ��
to enter upon the above mentioned property for inspection purposes. (We)agree CONSTRUCTION LENDING AGENCY
to save indemnify and keep harmless the City of Cupertino against liabilities, I hereby affirm that there is a construction lending agency for the performance
judgments,costs,and expenses which may accrue against said City in of work's for which this permit is issued(Sec.3097,Civ C.)
consequence of the granting of this permit. Additionally,the applicant understands Lender's Name
and will comply with all non-point source regulations per the Cupertino Municipal
Code,Section 9.18.
Lender's Address
Signature Date 12/13/2017 ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR.
PERMIT NO: B-2017 1267
20813 STEVENS CREEK BLVD STE 250 CUPERTINO, CA 95014 (326 32 052)
GIDEL & KOCAL
CONSTRUCTION CO
INC
CAMPBELL, CA 95008
OWNER'S NAME. STEVENS CREEK OFFICE CENTER ASSOCITATES
DATE ISSUED: 08/02/2017
OWNER'S PHONE.
PHONE NO: (408) 370-0280
LICENSED CONTRAC'TOR'S DECLARATION
BUILDING PERMIT INFO -
License Class B Lic. 4403050
Contractor GIDEL & KOCAL CONSTPUCTION CO INC Date 04/30/2019
X BLDG —ELECT _PLUMB
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
SCHAWK!- T.I. - OFFICE (3125 SF)
I hereby affirm under penalty of perjury one of the following two declarations:
REVISION #3 - CLARIFY ACCESSIBLE PATH OF TRAVEL PER
t. I have and will maintain a certificate of consent to self -insure for Worker's
INSPECTION CORRECTION ISSUED 12.22.17
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
Section 3700 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area.
Valuation. $225000.00
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
326 32 052
326
A (Tenant Improvements),B (Tenant Improvements)
and state laws relating to building construction, and hereby authorize
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
Additional) , he applicant understands and will comply with all non -point
source re u ations per the Cu, rt Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
�Q.
Signat Date 12.22.17
Issued by- SEAN HATCH
s
Date: 08/02/2017
R- L I N
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following two reasons:
t. 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: 12.22.17
I hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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.
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 with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
s. I certify that in the performance of the work for which this permit is issued, I
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 compliance with a Cupertino Municip C7ode, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety ode, Sections 25505, 5 S, al)nd1125534.
Code, I must forthwith comply with such provisions or this permit shall
V�4�Labor
be deemed revoked.
Owner or authorized agent
APPLICANT CERTIFICATION
Date: 12.22.17
N R TI LENDIN AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C )
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
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
and will comply with all non -point source regulations per the Cupertino Municipal
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature Date 12.22.17
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1267
20813 STEVENS CREEK BLVD STE 250 CUPERTINO,CA 95014(326 32 052) GIDEL&KOCAL
CONSTRUCTION CO
INC
CAMPBELL,CA 95008
OWNER'S NAME: STEVENS CREEK OFFICE CENTER ASSOCITATES DATE ISSUED:08/02/2017
OWNER'S PHONE:408-885-9801 PHONE NO:(408)370-0280
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class @ Lic.#403050
Contractor GIDEL&KOCAL CONSTRUCTION CO INC Date 04/30/2019 X BLDG _ELECT _PLUMB
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:
SCHWAK!-T.I.-OFFICE(3125 SF)
I hereby affirm under penalty of perjury one of the following two declarations: DEFERRAL#1-INSTALL CARD READER
1. I have and will maintain a certificate of consent to self-insure for Worker's REV#2 REVISE WALL TYPE FOR BATHROOMS-ISSUED 10-12-
Compensation,as provided for by Section 3700 of the Labor Code,for the 2017
/ performance of the work for which this permit is issued. REV#1 MISC REVISIONS REFER TO NARRATIVE 1 AND
phi, I have and will maintain Worker's Compensation Insurance,as provided for by NARRATIVE 2-ISSUED 9/13/2017
"h'"` Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$225000.00
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 32 052 A(Tenant Improvements),B(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 against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understan• and will comply with all non-point
source regulations per the Cupp n,, Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
/� z
Signator-,. /-2/"(---/— Date 10-12-2017 Issued by:SEAN HATCH
.. ' / Date:08/02/2017
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. I,as owner of the property,or my employees with wages as their sole installed without fust 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:10-12-2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. 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
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
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 Municipal Co e,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,255 ,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agen,;_/EZv, tri
APPLICANT CERTIFICATION Date:10-12-2017 -/
I certify that I have read this application and state that the above information is CONSTR• TION 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. I understand my plans shall be used as public records.
Licensed
Signature Date 10-12-2017 Professional