01040051 CITY
UoFU
PERTNO
IN DIVISION PERMIT CONTRACTOR INFORMATION:
"T'6CZpD}1RE$S:E ANZA BLVD PERMIT NO. 01040051
11 UU��dl LL..77 LL// G y��S�J
APPLICAI7ON SUP DATE
OwAt)g3°tffTSON' S MARKET 04/12/2001
/oG�G cG .� 5
PHONE: SANITARY NO. CONTROL NO.
C z z
w00 ARCHITECT/ENGINEER: BUILDING PERMIT INFO
Li W BLD LEC. LUMB MEC ,
L - I
LICENSED CONTRACTOR'S DECLARATION
S h 1 reran room,that I am Erensm ander :crena Ter q aommeecin ob Description
c provisions p g REFERENCE PMT 01040048 FOR PLANCHECK AND
rnFm with Section 7101001 of DWirision3 of me Business nue mefcssioro Code.and mylicense
<a W 6 icensel f lysy° `� Lic.a
xys _ PLUS 15 BELEC1000 (641 . 70) FEES OF $6283 .
10,O wr< 0 Conrrarmr �� CEIVED 4/11/01- TENANT IMPV. SUPERMARKE
ARCHITECT'S DECLARATION
Ei O 1 understand my plans shall be used as m.his,narcosis
u p O Licensed Pmfe.,mmil E .SOO�
i x o E OWNER-BUILDER DECLARATION C y'
m,w 1 hereby affirm that 1 am eamat from the Contractor's License Law our the L
I-z a fopowing mnsoo.(Section]031.5.Bosinev am Professions Code:Any city sir rounry
SFO which requires a permit to construct.alter,improve,demolish,or repair any s
d 3 m -pro t t N. q the applicant for such permit t rk .-g eJ.t _-
matn Ir-mealmr, tr tn'pruv sormecm,tmrtor L v (Chawer S -FLFIoorArea' w •�
Ice roncin 'l.5<noo]000) fDivision 3ofthe Busines nd.Pmresson,Code)i r�fy�,-'�j ( q'; r ., , ,.� �`eq .m' $1255(Y9lgation
or that he is ckerald the'ifmm and the basis for the alleged exemption.,Any violation 'Z "to pts�^ppP��-"`{{o'S,i..N. f ',•{
-of Section 703 L5 by any vppficarn fen a se;if subjects the applicant m a civil penalty 3 5 9kYbI 1P Y�V 0
of a°t more man five hundred doll...(S5n0 o,'.:• Occupancy Type
01,as owner of the property,or my employees with wages as their tele compcnsalms.
-
,will he suits.andntmcmre is not intended or offered for.ale(see.]oda: 101 - FOUNDAT �ired Inspections
Bu ,s
sins and Professions Code:The Contractor's License Law does not apply to an
owner of proany Who Wilds or immrrwc,thereon,and who does such work hhnself 102 - PIERS
or through his awn employees.provided that such improvements is it are not intended or _
-o@rid'(or Tale:1f,however the Wilding or improvement is wild within one�ear o[ —._.__. __ .__._
omalenon,the ownerbudder will have me burden of that be dm not build or. UFER___
or ml..j. p`°"`°g 104 - REBAR
improve mum°x o '
-
105---105---- CHOR 'BOLTS -- _.._01 o rem properly. exclusively ly t g with licensed contractors to ..
m met the project s ]taw B andProfessions
_ ...
Profu ns cm.)ThC drams 106 - SEWER & WATER
202 UNDERFLOOR PLUMBI
License Law does nor apply to an owner of property who builds or mproves dam o r
_and who contracts for such.pmjats wim.a convacmrts)liccmed puntaant m the
oim exempt under se. ,B&P C for this reams 203 UNDERFLOOR MECHANICAL
Owner Date 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION 205 - UNDERFLOOR INSULATION
1 hereny aRrm under prnalry oF,iijmy nue nnhe billowing declarations: 3 01 - ROUGH PLUMBING
0 1 have and will maintain a Certificate or Consent to.eta-instar,for workers 3 02 - TUB & OR SHOWER
Comp, ancon, as provided for by Section 3700 or the Labor Code, for the
Performance or the work for which this Permit is is.tom. 303 - ROUGH MECHANICAL
D I have ad wili maintain Works,',Compensation Insurance,as oeypooed by Sesmart 304 - ROUGH ELECTRICAL
_ 3700 of me Isbor,Code,for me penemrana of me work for wtdrh this permit is 3 05 - FRAME
iss 'My Worker's Compensation Insurance carrier and
Polity number ere:
,.,.
306, HOLDOWNS- - — -
. -• ., amcr GA S.aATLk��dcl¢y No:
e�CCRTIFICATION OF
EXEMPTION FRUM WORKERS'
" :,307•:'nINSULAT�IONi.'`'f:
fin ton nem not becomplemJifmSURANCE'., • .•- _-3'08',-,--,SHEETROCK--.-..._ . ._ _ ._ ...- .._. .-,---.. .
COMPENSATION IN
eprnnit is fm one hundred dollar 309 - EXTERIOR LATH
(slooj colas) LATH" -
310 -., .INTERIOR...
'y : 1 comfy Ilii , th art of m rk for whah m a t s Isa m,1 ,0
huts t employ any Nixonany r . ro become rob/at m the Weaken' 311 - SCRATCH'"COAT
Com,x,o4airm Laws of Califivarma.Date - - 313--" , ROOF._.NAIL
NOTICE TOin to APPLICANT. lirmakingm CertificatecoExemption.you should
Was, 501 FINAL ELECTRICAL ENERGY
Opbacsubject r me W k r Compensationp of the LaborCode,you mud
forthwithamply ithschp provisions pc tnadxe erenked. 502 FINAL PLUMBING ENERGY
z pe t s ' n .. .__ _. ._ -. ..
ncervcY 503 - -FINAL MECHANICAL ENERGY" 1
ahhx"
�' '� of theo k forhl'h'thbinding g age y f be arfo arca•. }.
issued fS
309]c :cj 504 - FINAL BUILDING ENERGY
.w p I<a, � Ymatlnvenaffirm that ne em cn 1 LENDINGasmtematmeabovvmrormations505 ...FINAL ELECTRICAli. ... - - .. . - .
. � z :Lane Add l
U O 506 - GAS TEST ''
'kT+ E.r correct.I agree to comply with all city and county ordinances and slate laws relating' 507 - FINAL PLUMBING
U mWilding construction,and hereby'aumorizerepresentinnesofthis city toenter upon SOH - FINAL MECHANICAL
W the abovementioned property forinaction purposes. ,
L (Wejagree 16 save:indemnify and kap harmless the City'of Culicnino againn 509 - FINAL GRA
Z) liabilities,judgments.costs and cNa rale.which may in any way seem e against said /'Y
U .z. City °asequence ofThe granting motet.permit "' 510 N G/`f- /
*PPAON ER STANDS AND WILL COMPLY WITH ALL NON:POINT ` kr,s /��'7 (' p/O7iGON Issued wn - at0 v !ill ' /ppnranvcommrmr ; ;. Date"- Re-roofs-HAZARDOUS MATERIALS DISCLOSURE
Will
the
future building occupant srde'a handle hizudous material
Type Of.Roof _ ,..,. _.. ..-_....... .
las definm by the Cupertino Municipal Cm Chapter9.12.and the Health and Safety „._M• y {.,; ,r - '-
;Code Section 25532163 sn
DYs 0No Ilv i. s. I 04 .r";'I• k.5 F
r^' ARTOOfs shall be,inspec[ed prior to-any roofing.ma[eria] being installed.
Will me applicant future building occupant useequipment devices which If a roof is installed'without first obtainingan ins ecttoit;Ita tee to remove
"it Hazard .tar t t defnm b3 th Bay Area A Quality M ge at P g
Disco f all new materials for inspection. Applicant understands and will comply with
❑Yes ❑Np all`non point source regulations.
' 1 have read the ha dots ¢dal a menti under Ch t 6eandilthe
'CShf buI Halm&Safetyfm<Sect un25505titis and25536lpundersmm ten
„iRhe bh in da>notments l3 have usi.bc mant¢mthe' ----_ ..--.... _..... .. .... . ._. .--. ... ... . ..-_. _.-- ..._
y¢.pori bJ ry tdnotify
ac in of mi'reQaircm2nts which must M met prior m issuancc'of a Cenifica¢of
3 -r
P;
'• x - -- ...:.. ..
.. ... -._. .-
- Date of Applicant
sir or umored gcm' DataAll covengs to be Class "Brorbetter
OFFICE