B-2017-1009 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1009
19429 STEVENS CREEK BLVD CUPERTINO,CA 95014(316 20 115) HOMEOWNER •
BUILDER
OWNER'S NAME: MAIN STREET CUPERTINO DATE ISSUED:10/19/2017
OWNER'S PHONE: PHONE NO:
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor HOMEOWNER BUILDER Date 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:
MARRIOT(RESIDENCE INN)-BAR AND LOUNGE;T.I (2,265 S.F.)
I hereby affirm under penalty of perjury one of the following two declarations:
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.
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
permit is issued. Sq.Ft Floor Area: Valuation:$100000.00
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 20 115 A(Tenant Improvements),A(Tenant Improvements),A
representatives of this city,to enter upon the above mentioned property for (Tenant Improvements),A'(Tenant Improvements),A
inspection'purposes. (We)agree to save indemnify and keep harmless the (Tenant Improvements),A(Tenant Improvements)A
City of Cupertino against liabilities,judgments,costs,and expenses which (Tenant Improvements),A(Tenant Improvements),A
may accrue against said City in consequence of the granting of this permit. (Tenant Improvements),A(Tenant Improvements),A
Additionally,the applicant understands and will comply with all non-point (Tenant Improvements)
source regulations per the Cupertino Municipal Code,Section 9.18.
Signature Date 10/19/2017 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
OWNER-BUILDER DECLARATION 180 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: Issued by:Abby Ayende
1. I,as owner of the property,or my employees with wages as their sole Date:10/19/2017
compensation,will do the work,and the structure is not intended or offered for
le(Sec.7044,Business&Professions Code) RE-ROOFSd
I,as owner of the propertyam exclusively contracting with licensed •
All roofs shall be inspected prior to any roofmg material being installed.If a roof is
contractors to construct the project(Sec.7044,Business&Professions Code)• installed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm under penalty of perjury one of the following three declarations: inspection.
1. I have and will maintain a Certificate of Consent to self-insure for Worker's
Co. .enation,as provided for by Section 3700 of the Labor Code,for the _ Signature of Applicant:
e s e °nuance of the work for which this permit is issued. Date: 10/19/2017
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
permit is issued.
3. I certify that in the performance of the work for which this permit is issued,I HAZARDOUS MATERIALS DISCLOSURE
shall not employ any person in any manner so as to become subject to the I have read the hazardous materials requirements under Chapter 6.95 of the
Worker's Compensation laws of California. If,after making this certificate of California Health&Safety Code,Sections 25505,25533,and 25534. I will
exemption,I become subject to the Worker's Compensation provisions of the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Labor Code,I must forthwith comply with such provisions or this permit shall Health&Safety Code,Section 25532(a)should I store or handle hazardous
be deemed revoked. material.Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
APPLICANT CERTIFICATION will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I certify that I have read this application and state that the above information is the Health&Safety Code Sections 2 505,2553 and 25534.
correct.I agree to comply with all city and county ordinances 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 Owner or authorized agent:
to save indemnify and keep harmless the City of Cupertino against liabilities, Date:10/19/2017
judgments,costs,and expenses which may accrue against said City in CONSTRUCTION LENDINGAGENCY
consequence of the granting of this permit. Additionally,the applicant understands I hereby affirm that there is a construction lending agency for the performance
and will comply with all non-pointsource regulations per the Cupertino Municipal of work's for which this permit is issued(Sec.3097,Civ C.)
Code,Section 9.18.. Lender's Name
,��I ILender's Address
J nat \ 1f`-Il Date 10/19/2017
• ARCHITECT'S DECLARATION'