B-2018-1974 Permit CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1974
23500 CRISTO REY DR CUPERTINO,CA 95014-6527(342 54 999) QUIRING GENERAL
LLC
FRESNO,CA 93727
OWNER'S NAME: DATE ISSUED:05/01/2019
OWNER'S PHONE:650-944-0112 PHONE NO:(559)432-2800
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#973147
Contractor QUIRING GENERAL LLC Date 05/31/2020 X BLDG _ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH_RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
THE FORUM-(N)2 STORY MEMORY CARE SENIOR LIVING
I hereby affirm under penalty of perjury one of the following two declarations: FACILITY(10,000 SF);ATTACHED PARKING STRUCTURE(16,500
1. I have and will maintain a certificate of consent to self-insure for Worker's SF);ADMINISTRATIVE OFFICES(1,100 SF)
Compensation,as provided for by Section 3700 of the Labor Code,for the
perfonnance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
e Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$13000000.00
APPLICANT CERTIFICATION 27600
1 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 34254999 B(Oflices),B(Offices),S-2(Low-Hazard R-2
representatives of this city to enter upon the above mentioned property for (Apartment),A-1,A-1,A-1,A-1,A-l,A-1,A-1,R-2
inspection purposes. (We)agree to save indemnify and keep harmless the (Apartment),S-2(Low-Hazard)
City of Cupertino against liabilities,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 PERMIT EXPIRES IF WORK IS NOT STARTED
source regulations per the Cupertino Municipal Code,Section 9.18. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Signature s'1111; 11 Date 05/01/2019
Issued by:Jasmine Archbold
OWNER-BUILDER DECLARATION
Date:05/01/2019
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. I,as owner of the property,or my employees with wacres as their sole RE-ROOFS:
compensation,will do the work,and the structure is not intended or offered for All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
sale(Sec.7044,Business&Professions Code)
inspection.
2. I,as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7044,Business&Professions Code).
Signature of Applicant:
I hereby affirm under penalty of perjury one of the following three declarations: Date:05/01/2019
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
3. I certify that in the performance of the work for which this permit is issued,I California Health&Safety Code,Sections 25505,25533,and 25534. I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
shall not employ any person in any manner so as to become subject to the Health&Safety Code,Section 25532(a)should I store or handle hazardous
Worker's Compensation laws of California. If,after making this certificate of material. Additionally,should I use equipment or devices which emit hazardous
exemption,I become subject to the Worker's Compensation provisions of the air contaminants as defined by the Bay Area Air Quality Management District I
Labor Code,I must forthwith comply with such provisions or this permit shall will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
be deemed revoked. the Health&Safety Code,Sections 25,505,25533,,and 25534.
APPLICANT CERTIFICATION „
I certify that I have read this application and state that the above information is Owner or authorized agent: '
correct. I agree to comply with all city and county ordinances and state laws Date:05/01/2019 $`
relating to building construction,and hereby authorize representatives of this city CONSTRUCTION LENDING AGENCY
to enter upon the above mentioned property for inspection purposes. (We)agree I hereby affirm that there is a construction;lending agency for the performance
to save indemnify and keep harmless the City of Cupertino against liabilities, of works for which this permit is issued(Sec.3097,Civ C.)
judgments,costs,and expenses which may accrue against said City in Lender's Name
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal Lender's Address
Code,Section 9.18.
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date 05/01/2019
Licensed
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1974
23500 CRISTO REY DR CUPERTINO,CA 95014-6527(342 54 999) QUIRING GENERAL
LLC
FRESNO,CA 93727
OWNER'S NAME: DATE ISSUED:05/01/2019
OWNER'S PHONE: PHONE NO:(559)432-2800
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#2Z3147
Contractor QUIRING GENERAL LLC Date 05/31/2020 X BLDG _ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH RESIDENTIAL COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
THE FORUM-(N)2 STORY MEMORY CARE SENIOR LIVING
I hereby affirm under penalty of perjury one of the following two declarations: FACILITY(10,000 SF);ATTACHED PARKING STRUCTURE(16,500
1. I have and will maintain a certificate of consent to self-insure for Worker's SF);ADMINISTRATIVE OFFICES(1,100 SF)
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
pernut is issued. Sq.Ft Floor Area: Valuation:$13000000.00
APPLICANT CERTIFICATION 27600
1 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 34254999 B(Oftices),B(Offices),S-2(Low-Hazard R-2
representatives of this city to enter upon the above mentioned property for (Apartment),A-IA-1,A-1)A-1,A-1,A-1,A-I,R-2
inspection purposes. (We)agree to save indemnify and keep harmless the (Apartment),S-2(Low-Hazard)
City of Cupertino against liabilities,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 PERMIT EXPIRES IF WORK IS NOT STARTED
source regulations per the Cup�,ertir�o Municipal Code,Section 9.18.
:. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Signature . .: . `, Date 05/01/2019
OWNER-BUILDER DECLARATION Issued by:Jasmine Archbold
Date:05/01/2019
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons:
1. I,as owner of the property,or my employees with wages as their sole RE-ROOFS:
compensation,will do the work,and the structure is not intended or offered for All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
sale(Sec.7044,Business&Professions Code)
2. 1,as owner of the property,am exclusively contracting with licensed inspection.
contractors to construct the project(Sec.7044,Business&Professions Code).
Signature of Applicant:
I hereby affirm under penalty of perjury one of the following three declarations: Date:05/01/2019
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
performance of the work for which this permit is issued.
2. 1 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 HAZARDOUS MATERIALS DISCLOSURE
permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
3. I certify that in the performance of the work for which this permit is issued,I California Health&Safety Code,Sections 25505,25533,and 25534. I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
shall not employ any person in any manner so as to become subject to the Health&Safety Code,Section 25532(a)should I store or handle hazardous
Worker's Compensation laws of California. If,after making this certificate of material. Additionally,should I use equipment or devices which emit hazardous
exemption,I become subject to the Worker's Compensation provisions of the air contaminants as defined by the Bay Area Air Quality Management District I
Labor Code,I must forthwith comply with such provisions or this permit shall will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
be deemed revoked. the Health&Safety 25534.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is Owner or authorized agent: ; .
correct.I agree to comply with all city and county ordinances and state laws
Date:05/01/2019
relating to building construction,and hereby authorize representatives of this city CONSTRUCTION LENDING AGENCY
to enter upon the above mentioned property for inspection purposes. (We)agree I hereby affirm that there is a construction'lending agency for the performance
to save indemnify and keep harmless the City of Cupertino against liabilities, of work's for which this permit is issued(Sec.3097,Civ C.)
judgments,costs,and expenses which may accrue against said City in Lender's Name
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal Lender's Address
Code,Section 9.18.
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date 05/01/2019
Licensed