05030022 CITY OF CUPERTINO �s�a,� � pi,k°-� ^fin" �7p ♦` Ts'
BUILDING DIVISION PERMIT �iCONT.R:ACTUR Nl ORMATT
BUIL DING ADDRESS: F G & T CONSTRUCTION PP�MITN.05030022
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY 0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSt� t� e! l�
300 =thatEDCONiRdunderSDEConsorCON JobDescri tion
I ion 70 affum Net 1 am of Me
Bu under and
I'mr ss of tCode, 9(commencing P
with Section and
c of Division 3 of due Business and Profassiona Code,and my license h
mmumtoeanec
5�? Limn Sa�tO 4 :2 7 TI--NEW CHECK STANDS/ADA RESTRMS &
Dole Co
'cX Lmon""
ARCHITECTS DECLARATION REPLACE GONDOLAS/
zG ntracmr
0 7j
1 understand my plan MJI be used u public rcrnNs -
Q Licensed Profeuional
OWNER-BUILDER DECLARATION
1 hereby AMM that I am exempt from 0c Corer arm's Lkenm Law for the
i a D following won.(Section 703 I.S.Business and Profession Code:Any city or aunty
M I E which requires a permit to cmnmraL alter,imi mm.demolish.nr repair any structure
F Z i prior to its Issuance,also requlrw the applicant for such permit no me a signed suxment
< Met W is licensed Nrmsthuo to provlsios of Me Contrmurs license Law(Chapter 9 Sq.Ft. Floor Area VaSi1�t 000
B (commencing with Section 7000)of Division 3 of the Business and P ficromm Code)Of
— But he is exempt Marchese and the bila for the alleged exemption.My vialadon of
Section 7031.5 by airy applicant for a permit subjects due applicant to a chil penalty of APN Number Occupancy e
not mom than It hundred dollen(35001. P y 'T7y P
❑I.ummoftbpmpmy,ormyunplaymwiNwegauth mkemnpewdon, 32610063 . 00
will do the work,and Ne suuauto is notimmnded oraaetcd forum(Sm.7011,Business Required Inspections
and Profession Coale:Tb Con racmrs License e Law does set apply an in Owner e( q P
property who bu ilds w im prose demon,and who aloes such work himself or tlarough his
Own employees,provided that such impmmmau ate not intended oro@rod forule.if,
heaver,Ne Wilding or Improvemest is mid within am your of completion.the owner.
builder will hem the Wrdan of proving that he did not Wild or improve for purpose of
cont
❑1,u Owner of the property am eulusively contracting with licensed eonvamrs to e
am Law due project(Sea o in t Busiower of and property
who
Code:)Thews Moncton.Lid
roue law tlaa not apply to an sorter of Property sold selids orimprow Conus,and
who contracts for pmkcu with a conummrta)licensed pursuant m the Contractoh
Licewe law. '/A�
❑I am exempt under Sea .B A,PC fw N4 wan ✓/'t n
Owner Data AdiL suit
WORKERS COMPENSATION DECLARATION //`/4/p�'' a,�
I he, aBirm under penalty of perjury one of the following dttlandomo ��
ave end willmalnuinaCertfiwu of Conumroml6insum for Wotefs Compere 111////
on,u provided for by Section 3700 of the labor Code.for the performance of the
work for which this Permit is issued.
❑I have and will maintain Workers Compensation Insurance.as required by Section
3700 of the Labor Code,for the performance of Ne work for which this Permit is VuaW.
My Workers Compensation burdensome tams and Policy number m:
Carle�/g'fF �/'Wl'Policy No.:O Y6 a)f 37
CERTIFICATE OFEK PION FROM WORKERS'
COMPENSATION INSURANCE .
('Dhhrecdon need notbecmnpmed if W permit u foram hundred dollars(5100)
or less)
. I certify that In the performance of the work for which this permit is issad.I shall nos
employ any person in my manner an as in become subject to the Workeri Compenudon
Laws of California.Dem
Applicant
NOTICE TO APPLICANT:If,after making this CeniOeem of Exemption,you should
become subject to Ne Worker's Compensation provision of Ne Labor Cada you muss
.J7 O forthwith comply with,such provHinu w this Permit Nall W ticemed towkR
e
.7y CONSTRUCTION LENDING AGENCY -
[.w I hereby affirm dust ten is a construction lending agency for Me per(mm.of
to work for which tis pewit is Issued(Sec.3097.Cir.C.)
W�Q Leneet'sName
Q z Lenders Address
V Q 1 certify that 1 ham red Ws application and sum that to abow Information Is
PL atreeL I agree to comply with all city and ewnty ordiromms and sum laws totaling to
Q building construction.and hereby autorm mpmnenutives of this city to cnmr upon doe
S elrovcmmGoned property for iupection purposes.
(We)agree in ave,indemnify and keep harmless the City of Cupertino against
wW liabilities,judgments costs and expenses which may to any way acme against mid City
inansmganc to grantingofthpermit.
APPLIC RSTANDS D WILL COMPLY WITH ALL NON-POINT Issued by: do Date
SOUR RE ATIDNS.
Re-roofs
Sign tanu'Ce rectorI Amt
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will tlm applicant or future Wilding=upset amus or handle handous material
as donned by the Cupertino Municipal Cock,Chapter 9.12.and the Health and Safety
code,Section 15532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building Occupant um equipment Or deices which If a roof is installed without first obtaining an inspection,I agree to remove
hnardnus air anummants a defined by due Bay Area Air Quality Management all new materials for inspection.
IV'?
❑Yrs
Iia trc huaNausmamdaIs requirements under Chapter 6.95 or the Califoo-
tits etYCede,Sretiau15 ,15533 mal 255M.1 unhnuM them Oft Wilding
Ja of duly haw a mnm4 duo my rtspansbillly to no0(y due occupant of due
rc ins whichmuubeme or iaumaofaCcnifmamoy0cc 7� Signature of Applicant Date
(a o
Owner w automed eg m -
Dow
All roof coverings to be Class"B"or better