09100078 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10486 STERLING BLVD CONTRACTOR:TBD-TO BE DETERMINED PERMIT NO:09100078
DATE ISSUED: 11/16/2009
OWNER'S NAME: CITY OF CUPERTINO
PHONE NO:
OV^ER'S PHONE: 4087773200 '
[� LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# MECH f- RESIDENTIAL r- COMMERCIAL
Contractor Date
JOB DESCRIPTION:CONSTRUCTION OF A NEW NEIGHBORHOOD PARK WITH
1 hereby affirm that I am licensed under the provisions of Chapter 9 DRINKING FOUNTAIN LOCATED AT 10486 STERLING
(commencing with Section 7000)of Division 3 of the Business&Professions BLVD-NEAR BARNHART CT.APPX.26,010 SQFT-
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
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.
I have and will maintain Worker's Compensation Insurance,as provided for by Valuation:$500000
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area:
permit is issued.
APPLICANT CERTIFICATION APN Number:37523046.47PARK Occupancy Type:
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 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
C OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's
I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the
California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued.
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
1 have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District 1 will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I O 'er or autho d agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
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 of wor s
sued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is is
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
cc -nd expenses which may accrue against said City in consequence of the
gi g of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulation er the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18. Ga"Lk—/
/
Signature
r L Date �� Licensed Professional