03030090 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTR INF,OR, M TIONa,
BUILDING ADDRESS: PERMIT Npb 3 0 3 0 0 9 0
`vNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
(� (�
°00 LICENSEDCONTRdoccurSDEConsofCON
-
r 1 therebyom70 affirm Thal I am licensed ander add
Profession,
onCWde v my license is Job Description
^� with ullforeandiBecDIvlslon 3Ofthe Rminca and Professions Cnde,and my license is
mmneClaentlerree`' TENANT IMPROVEMENT/RESTAURANT
p��
License Class Lic.N
�'a Date_Conlraetar
ARCHITECTS DECLARATION
eauIunderriandmyplans shall heused aspublic records TEMP. PERMIT 403110117 (EXPIR. 12/21/03)
y Licensed Professional
I OWNER-BUILDER DECLARATION -
a S1 hereby affirm that I am exempt from the Contractor's License Law for the
_a IS following reason.Section 7131,5,Business and Professions Code:Any city or county
which requims a penail to cnnstrum,alter,improve,demolish,or repair any structure
yin prior l.its issmnce.also requires the applicant for such permit to file a signed statement
< 'hat he is licensed pursuanuo the pmvisiom of do,CarrollLicens Law(Chapter 9 �q. FL Floor Area Valuation .
xP� (commencing with Section 7")of Division 3 of the Business and Profcasiona Code)or (yw.alyy�y
i Nat W is eaemmt Ih akffom and doe bests roe Ilse alleged exempume.Any violation of Il � . - _ $247900
Section 7031.5 by any applicant for a permit subjects the applicant 0 a civil friendly.! t'!_APN Ndmb r I panty Type
nal more Nan five hundred do11ars(S50).
❑ I,as owner of the first or my employers with wages az their sole compensation,
will do the work,and the sweture is not intended or offered for dak i.e.I..Business a t ♦ a � .:,-
and professions Code:The Contractor's License law dears not apply to as owner of Required Inspectiti
property who builds or improves thermon.and who does such work himself.,through his u 'f
own employes,provided that such improvements sae not founded proffered for sale.if. u
however,the building or impmvcmrnt is sold within one year of completion.the owner,
builder will haw the burden of moving that he did not Wild or improve for propose of
sale.).
A1.es owner of Ne p ads n t am exclusively contracting with licensed contractors to
�onstmct the pmjce .Dtnicess and Professions Code:)The Contractor's Li.
cense Law d I apply m op owner of property who Wilds or improwi thereon,and
who contra forsuchpmjeetsm�in a eontaamons)licensed pursuant to the Contractor's
Licca.
❑I am a rept under Sec. .B h P C for Nu rtazpn
ncr D
1 RKER' OMPE ATION DECLARATIOIO
N
1 hereby Niro under penalty of perjury one of the following dcclantions:
❑1 haw and will mountain a Cenifisle of Consents.seff-ho nefor wrrkerSC.Mix.-
aation,az provided for by Section 3700 of the labor Code,for the perfomtarce of the
work for which this permit is issued.
T have and will maintain Worker's Compensation Insurance,az required by Section .
3700 of the labor Code.for Ne performance of the weak for which this permit is issued,
My Workers Compensation Insunntt canner and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seetion need not he completed if the permit is foronc hundred dnflara(SIUB
ir Iss)
1 Celli fy that in 01 ^mors ,aor the work for which this permit is issued.1 shell not
employ any to nin anym bac9nc subject to tW Workcrr Compewuon
taws"r r,'r,". n.
Applic
NOT 0e NT.If cr matrngthms Contfum of Eacn,you should
WcomC subject to the Workers Compensation provisions of the tabu Code,you must
.J O ford ith comply with such pmvisimma or Npshal
is ermit l W deemed evoked.
ZN CONSTRUCTION LENDING AGENCY
1-+ Ihereby aRrm that there is a cpmwninn lending agency for the performance of
!Ythe work for which this permit is issued(Sec.3041,Co,C.)
W A lender's Name
OL
Uz Lender's Address
c) Q 1 eenee Nn T have read thisapplication
and county
and amre that the above infmmatiun is
0 U Wilding construction,
agree to comply with ill city and countyorJinvmCv and su¢laws rolmingm
U ancow-gcrnswdiugand hereby incre mi rempresentatiws of this city mcnmr upon the
,r 4 above-(We)omod goo,to aw,rty for emnify an locep hs
(We)agree m saw,indemnify and hick may
in an the City of Cupertino against
fy" N in
to
judgmenn epsnandexpeazeswhicM1 may in anyway accrue against saiO City
C)Z into c0tingothis permit.
^ APPL ANT UNDERNDF.RS ANDSs AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOUR E REGULATI S.
Rype ofs ^ r
Signal MoM., Date
HAZARDOUS MATERIALS DISCLOSURE T of Roof \
Will the applicant or fumo building wcupapt sem or handle Health anmatenil
az tleRned by the Cupertino Municipal Cudc.Chapter 9.12,and the Health and Safety
Code,Seem..25532M)? All roofs shall be pinspected prior to an roofing material being installed.Np
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit ha/ardour air contaminants az defined by the Bay Arca Air Quality Management all new materials for inspection.
District? /
Oyer Q4u
ave
mrials reyuimmenn under Chapleru.95o(thcCalifor-
niaHcalNh505.25533.d25534.1.ndcrstandthuifthe Wilding
dispute. toism res namilitymnotify IMecorealorthe
touimmenant tweet, ccmheatoofacuencyy. Signature of Applicant Date
owne Dam All roof coverings to be Class "B"or better