04040108 CITY OF CUPERTINO ' ' �F^b'
BUILDING DIVISION PERMI'� r3„�CONTR:AC�'TQR`INF.ORMAT�I� '
IDI sy ta�'Utsb'0.2.k - < ,R'd'�,u•
BUILDING ADDRESS: COFFEE BEAN CAFE/REDA ALSU "04040108
OWNER'S NAME: FERMITLSUEDATE
NE: SANITARY N0. CONTROL NO.
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
you LICENSED CONTRACTOR'S DECLARATION O O
ro F 1 haacby ercrm mat I am fiavM ander provirmns tr ch.Pmn v(agganemg Job Description
wif Seen... )).f Division Sof me Business and Professions Cndo,end my recruit
n
" in full forte and affect TI— —COFFEE BEAN CAFE
M = Class_ License ns Lia.,
q
n H m Dam Contractor
1° ARCHUECI'SDECLARATION JUL 2 2004
�i 1-1 1 understand my plans atoll he used a public accords
JyU
=DgLICCnsCd Professional nI1I� A f(� A�f/�Ia�gype,
OWNER-BUILDER DECLARATION SUNIODING
<I I hnahy alum mal I am exempt from he ConuacmYs License Law for the Y V w
a o following mason.(Section 71131.5,Business and Pmfessions Code:Any city or county
m which requires a permit to construct,altar.improve,dcaudsh,or repair any suuctum
prior to its issuance.also mquiry the appliam for such permit to Ble a signed summent
that he is licensed pursuant to the provisions of the Comranori Liccnm Law(Charter 9 Sq.Ft. Floor Area Valuation
,,-c (commencing with Section 70M)at Division 3 or me B usiness and Professions Conde)or
i $ hat ys is exempt thmafrmn and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant fon permit subjects the applicant to a civil penalty of 34AP1`6I9tMci0 0 Occupancy Type
not mom than five hundred dollars SSW).
I,M owner of the property.or my employees wire wages as their sole compensation,
Will do Out wish,and the edema is not immnded or offered for sale(Sec. Business
and Pmfessions Code:The Contractor's License law does not apply m an owner of Required Inspections
property who builds or improves thereon,and who docs such work himulf or through his
Own employees.provided mat such impmwmenu we not intended oruffered forsam.If,
however,the building or improvement is sold within one year of completion,me owner-
builder will haw Ore bund.of Proving mor he did nm build or improve for Purpose of
talc).
1,as owner of me property,am exclusively contracting with licensed contractors in
c acct me project(Sec.?844,Rusinecs and Poferiov Code:)The Contractor's Li-
cense law does not apply to an owner of pmpeny who builds or improves hneon,and.
who contncu for projects with a convacmKs)licensed pursuant to Ne Conuaaori
Lkcvc law.
❑lam pt Sec ,B&PCfor h)msson
G ner� Da
WORKERS COMPENSATION DECLARATI
I hereby affirm under penalty of Perjury one of the following declaradome
1 have and will mumein a Carolinian,of Covent m self-insure for WorkchCom act-
ration,u provided for by Section Jt00 of du labor Code,for the performance of the
work for which this permit is issued.
0 1 have and will maintain Wool Compensation Insurance,as required by Second
3770 of me W i or Coda,for me perfmmance of the work for which this permit is added.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier, Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nissection need not he completed if the{argil is forone hundred dtllars(SIM)
ess.)
1 anify met in do peffoguao of the work for which this permit is issued,I shall not
employ any person in any manner or,as to become subject to the Workers'Compensation
Laws or California,Dan,
Appli ant
NOTICE TO APPLICANT:If,after making this Campeau,of Exemption,you should
become dhjaa to he Worker's Compo rwnion provisions of the lahnr Code.you must
.,O fortwih comply with such Prosecutors or this permit shall be dammed onmucd.
Z7A CONSTRUCTION LENDING AGENCY
[� I herby affirm mat mere is a couarominn lending ageaay for the peafurmana of
Cnot work for which this permit is issued(Sec.301 Ci,C.)
aQ Lender's Krone
5 z Cendant Atltlmss
U 0 1 arufy that 1 hese read his application and sum Out he above informniun is
F correct.1 agree to comply with all city and county tNinences and sum laws relating to
0 U building covwction.and hereby auhariae representatives or his city to cost upon the
[Ll shove-mentioned property for isspccutm purpose.
(-'1 (We)agree to rave,indemnify and keep harmless the City of Cupertino against
liabilities judgmental,cast and expatriates which may in any way accmc against said City
U in consequence of he Instant,of his parmit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU REG ATIONS.
G
Re-roofs
Sig re of ApplicaHAZAR cOr
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WillmeapplieMtorrummbui ingteeupegnme athandla hvardedus amusing
as dcfncd by he Cupertino Mimic' I COM,&It 9.13,and the Hcalth and Safety
Code.Section 25531(.)? All roofs shall be inspected prior to any roofing material being installed.
CYes
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future It Idiag occupant use equip nam or devicss which
7d�
havardous air conuminanu cgncd byhe Bay Amo Air Quality Management all new materials for inspection.
❑Yes N1 have mad hehva wsmarerialsmquimmcnuunderChapter6.950!daCalifon
calh&Safety Cale,ScNuns 25505.25533 and 255]4.1 undersuntl hat ifhe building
not curtcmly how a tenant.Nat it u my mspossihility m nuly the mcupam of he
ass wit mug xmapriorwissuance OracenirmamofOccupancy. Signature of Applicant Date
✓.
O cr authorized agar Date All roof coverings to be Class"B"or better