05110065 CITY OFCUPERTINO = g' '' tf,477
BUILDING DIVISION PERMIT CONTRACTbR INF ItMATIQI i
BUILDING ADDRESS: RON PARIS CONSTRUCTION CO "°-05110065
ER'S NAME: PERMIT ISUB DAIS
KUMUD GROCERIES 3575 STEVEN 01/12/2006
PHONE: SANITARY NO. CONTROL NO.
(408) 296-5926
ARCHITECI7ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Sop LICENSED CONTRACTOR'S DECLARATION
1 hemby a10rm that 1 am limewd under provision of Chap.r 9(commencing Job Description
IN Section 70110)ofDividon 3.fd,.Beat.and prufueions Code,and my liters,Is
^� in full fotoe.nd erten. TI--GROCERY STORE
j1zDaWr
nrw Clue Lica
DJs, U..# TEMP PERMIT #06010036 (EXPIRE 02/05/06)
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ARCHTTECrS DECLARATION
I undersand my plana shell be used u public mends
Licensed Profcsdonai
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law rot the
to 0 following rtuon.(Section 70313,Business and protestations Code:Any city or county
$ which requires a permit to construct,atter.Improve,demolish,or mpair any strocture
�L^ prior to its issumen,alsu requires the applicant for such permit in rile a signed IMWmem
zFF< thel M is licensed pursuant to the provisions of NL1
e Contractor's ce'ue Law(Chapter 9 Sq.Ft.Floor Area alt's "000
3$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or //�/
3
that he 0 exempt Nemfrom and the but&for the alleged emmptim.Any violaden of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN NumberOccu enc
trot mom than live hundred dollars($51)(1), �+ l5 y, Yp
Luewnerofthe y poyer, ger pc 35917001 . 00
❑ propmy,ar m w I with m u theh tole tom nu0on, �s n.
mildotheworemeldt mocuu e11.0(i ended"Offered fonsele(S.C.7061.BusinessRequiredns
and Professions Colt:The Contractor's License law don not apply to an owner of
property who Wildaorimprower theme.,andwhodeeasuchwerklace ar through his
V /J({ yI�,���jtiv
awn employees,provided that such lmprewments sant Intended eroRertd forule.If. iI�. �✓
however,Ne building or improvement is sold within ere year of camplcdon.me owls rg
builder will hew the burden of proving that he did not Wild w improv for purpose of (J
ole.).
owner of the property,am exclusively contracting with licensed conuxWrs W
C utroct Ne project(Sec.701x,Business and Professions Code:)The CmtrwWr',U.
tens,law does not apply to an owner of property who builds or improves thcrton,and
who contracts fanWoh projects with a eanuactar(s)licensed pursuant W the ConuagoYs
License law.
❑I am uempl under See _._.B&P aamlhirtaa6r
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OR� .63 F NSATIONDECLARATION
I hereby ainmall nstyof perjury one of the following clodarstions:
❑I haw and will maintain.Cerdric.0 of Consent W aelfdnsum for Worker'sCompem
fatten,as provided for by Section 3700 of the labor Code,for Ne performance of the
work for which this permit is Issued.
❑I have and will maintain Worker's CompeuNen huwance,as requined by Section
3700 of the labor Code,for Ne performance of tle work for which Nis permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
Cartier. Policy NO.; _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Climaxed.Wood rot M completed NOW permit Is foroWohumdred d.11.($100)
or loss.)
1 certify Not to the performance of the wor far whicl thla permit t&issued,l halt not _
employ any person to any manners Wbc sub cl orkcn Cempcuatian .
L....f Ca]Ifomia. q
APPIt
NOTICE TO APPLI A A f a er making this CenlRcam of Exemption,you should
become suhject to the Worker's C.,openestion pmvWons of the labor Code,you meet
,J O faMwith comply with such prmvisiou or this permit shall be doomed nevokcd.
Z 5; CONSTRUCTION LENDING AGENCY
(.w.N-� I hereby alfum that then sea construction lending agency for the performance of
C the work for which this permit is issued(Sec.3097,Cih,C.)
W�Q lander,Name
]z Lender's Addwss
J Q I certify thn I haw read this application and sum that the show information u
ly,F c urrOcL l agree W comply with all city and county ordinances and auto law,totaling in
Ot, building construction.and hereby.urhodee mpmessmadws oflht&city W color upon the
[T7 above-mcndoned pmpcny for inspection purposes.
LL (We)agree W sew,indemnify and keep harmless the City of Cupertino suint
w.t to liabilities,judgments.cents and expense,which may In any way same against said City
(„)7 inconsegoenc,ofthe Lrant"So"h 'mil.
(=i
APPLICANT UNPSNA WILL COMPLY WI ALL No$oiNr Issued by: Date 'L Q
SOURCEREGUNS,
! f lit 4 Re-roofs
Sianuum ofA D..
HAZ DO S MATERIALS DISCLOSURE Type of Roof
Will the applicant o building OaupaILecau or handle harardeu material
u defined by the Cupertino Municipal Code.Chaps 9.13,aha the Health and Safety
e,Section 25532(4)7
❑Yu ❑Nr All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtainingan inspection,I agree to remove
VIII the applicant or Tows,building Occupant um equipment or devices which � g
emit havardons sirconmminants as defined by the Bay Arta Air Quality Management all new materials for inspection.
District?
❑Yea ❑Nu
I have mad the hasardmnmaWda requiromcnu underChap.r6.95 ofthe Califon
rite HCIDth&slelycode,Seco.25415133 aru125534,l undcrsmnd thulrthe building
duos rot cunenily h ..nanq t it i my rtspoMi ily m notily th upanI rp¢
mqulrem,no which met ar t&tq mine..OrOccu e3'' Signature of Applicant Date
Z t]
Owner ser euthodzage All roof coverings to be Class"B"or better
Do.