B-2018-0211 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR; PCRMIT NO:B-2018-0211
10055 MILLER AVE STE 102 CUPERTINO,CA 95014-3468(369 06 011) OWNER/BUILDER
OWNER'S NAME:LEE FUJIMOTO LO&ASSOCS LLC DA'Z'E ISSUED:07/19/2018
OWNER'S PHONE: PRONE NO;OWNER BUILDER
LICENSED TRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.If
Contractor OWNER/BUILDER Date X BLDG_ELECT_PLUMB
I hereby nl'lirm that[am licensed under the provisions of Chapter 9(commencing MECH_RESIDENTIAL X COMMERCIAL
with Section 7000)or Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
LO DENTAL CARE-T.1-(1240 SF)
I hereby affirm under penalty nl'perjury one of Lite following two declarations:
r. 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
Jet formance of the work for which this permit is issued.
z. I have and will maintain Worker's Compensation Insurance,as In far by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Flaor Area; Valuation:$90000.00
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 369 06 011 A(Tenant Improvenieots),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.
Signature Date 07/19/2018 Issued by:Jasmine Archbold
Date:07/19/2018
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.Ifo moria
r. I,as owner of the property,army employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
cmnpenta tion,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed Signature ofAriplicmn:
contractors to construct the project(Sec,7044,Business&Professions Cade), Date:07/19/2018
1 hereby affirm under penalty of perjury one of the yellowing three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 1 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
z. I have and will maintain Worker's Compensation Insurzncc,as provided for by I have read the hazardous nmterials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the wink 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
s. 1 certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store at handle hazardous
shall not employ a material.Additionally,should I use equipment or devices which emit hazardous
p y a y person in any manner so as to become subject to the air—taminants as defined by the Bay Aron Air Quality Management District 1
Worker's Cempeusntion 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 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall �__� .,..ApII
be deemed revoked Owner or authorized -
APPLICANT CERTIFICATION Date:07/1912018
1 certify that I have read this application and state that the above information isCONSTRUCTION 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 1RCITM'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Lice sed
Signature � Date 0 711 912 0 1 8 professional