04050023 CITY OF CUPERTINO xM; rm ro�z - "az�.a�em .a 'm
BUILDING DIVISION PERMIT CONTRACTQR"INIORMATION '.
BUILDING ADDRESS: COFFEE BEAN CAFE PERM ,"4.050023
ER'S NAME: PERMIT LESUE DATE
COFFEE BEAN CA \
ONE: SANITARY NO. �'CO TROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Lop LICENSED CONTRACTOR'S DECLARATION Job Description
F❑ 1 hereby affirm Nat I am licensed under provisions of Chaplar 9(commencing p
iW with Seei..7(XX)of Division 3 ofthe Business and Professions Code.and my license is
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p� in full force and effect DEMO
Z License Clan Lk.
�Fp Dam Contractor
�',' ARCHITECDTS DECLARATION
¢< I understood my plans shell W used u Public rsnNm
3 LL
In Licensed Professional
a0g OWNER-BUILDER DECLARATION 4a
.�<f 1 hereby affirm that 1 em exempt from the Contractor's License Law for the
p O following mason.(Section?OJ I.S.Business and Pmfessiom Code:Any city or County
S:
m which require.a permit to Construct,alter,improve,demolish.or repair any structure
v�'^ prior to its issuance.also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to Na provisions Of the Coacmri u
nuLitxnLaw(Chapter 9 Sq. Ft. Floor Area aluation
a (commencing with Section 7000)of Division]or the Business and Profusions Code)Or
y _
that M is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a Permit subjects,the aaPikant in a civil penaly of 3 WPI430dilacrO 0 OCC panty Type
not mom than five hundred dollars($500).
❑1,u the
work.
and
prpprny, DIY employees with wages u Neu sole wmperts inns
will do fc woh.end e: structure ii not intended Licerse Law dosed Out c applSecy
Orne4,Business
and Professions Code:The Cs thereon,License Law docs Out apply lf an owner Of Required Inspections
progenywho builds OTimprorvschicon,and who am not Intended!
himself alNrougb his
own employees.providedinori Natsuch improvements arcnot tarofC mploroetied for Owner.
builder ..the building or improvement is ust within one yearw improv foron.the owe of
builder will Mrs drt Wrdra of proving Nat a did not build w improve for purpose of
sale.).
❑1,as owner of Ne propcny,am exclusively contracting with licensed contractors to
construct the project(Sec.7614,Business and Professions Code:)The Contractor's Li.
cense law does not apply to an no,of progeny who builds or improves Wrimn,and
who contracts for such projects with a eonuactor(a)licensed pwseam to the Contractors
Lken Law
am EPL
See B A P C fo Nis moon
or lir=WDA. 5COMPENSATION/ \ DECLARATION
I hereby alTirmunder penalty of perjury one of Ne following ons:
I has and will mainain a Ccrtificau of Cmusim to Ulf-im, fO esCompcn-
r"ion,aa provided for by Swtion]700 of the labor Code,for the performance of roc
work for which this permit is issued.
❑1 have and will maintain Worker'.+Compensation Inions,u taluired by Section
31 of the labor Code,for the performance of the work for which Nis permit is issued.
My Workcrs Compensation Insurance carrier and Policy number tie:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nem not be completed if the permit isfnr onchundred dollars($100)
or mss.)
1 ccmfy that in the performance of the work for which this permit is issued.I shall not
employ any person iy mape�pu;y(o become sat to tiro Si'orken'Compensation
Laws of Califnmia Da ( 6!w
APPI'ant
O APPLICANT.IL afmr making Nis Ccnificam of Exemption,you should
id
bjKt to the Worker's Compensation provillOM Of the Labor Cmc,you must
.J Z fo th comply with such provisions or this Permit mall he deemed invoked.
z CONSTRUCTION LENDING AGENCY
Ihereby affirm that Nem is a construction lending agency for the performance of
a z
the work for which his permit is issued(Sec.3f39t,Co.C.)
V.1 Under.Name
� Lender's Amrtss
J 0 1 CeNfy that T have read his application and Bute that the above information is
IyF correct.l agree to comply with all city and county ordinances and slam laws elating to
O V Wilding construction.and hereby audiencerepmunatives of this City to enter upon the
above mentioocd property for inspection purposes.
(We)agree to ave,indemnify and keep harmless the City of Cupcnino against
fad Liabilities.judgments,coss and expenses which may in any way accuse against said City
U Z in consequence of the graming of this permit. Q
'^ APPLICANT UNDE TANDS AND WILL COMPLY WITH ALL NO -POINT Issued by: Date
SOURCE GULA NS.
mien A as rcen . La ata Re-roofs
vV HAZARDOUS MATERIALS DISCLO!SRE Type of Roof
Will Ne applicant or future building Occupant atom or handle haramous material
AM.
by to Cupcnino Municiipx ode.Chapter 9.13,and the Health and Safety
e.+croon zss]z(.3? -
p res 0 All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or forum building occupant use equipmentr dvi
If a roof is installed without first obtaining an inspection,I agree to remove
ces which
migt hpamo rdnus air contiminamm az defined by the Bay AAir Qualae
ily Management all new materials for inspection.
Disvict?
❑Yes
I have sad the hvardsms mamdalr mqui¢ments under CMplcr6.95 rf the Califon
nia HcalN&Safety Cmc,Sections 25505.1553]and 25534.1 undersand thatifh.Wilding /
dors not cum tidy hme a¢rant,that it is my responsibility to notify he occupant of Ne
requirtm wbw aslWmetpooltoemancerr,canifiaamr etr ay. Signature of Applicant Date
Ow' rdra.,Wn.<d.,ut Cto All roof coverings to be Class "B"or better