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CITY OF CUPERTINOx�,r
BUILDING DIVISION PERMIT W
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BUILDING ADDRESS: P
PERMIT NO.0 5,12 0111
19062 STEVENS CRK BLVD
OWNER'S NAME: P
PERMIT ISSUE DATE
0
03/10/2006
E: S
SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: B
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION J
Job Description
1 hereby afflrm We I Am IWensM under provisions of Chapter 9 (commencing P
P
with Section 70W)ufDI,IMOA 3 o the Business and Professions Cade. and m licence'
in (UIIIffnAc0,deQeur. � L
TI- SUPERMARKET -ALL MECHANICAL EQUIP ON ROOF MUS
LWg S
BE SCREENED -FOOD TAKE OUT ONLY -NO SEATING
�crs DECLARA ON I
INSIDE OR OUTSIDE IS ALLOWED.
1 underannd my plants Nall h used as public menftl. C�ls'7 ,
,.
Licensed Professional )
OWNER - BUILDER DECLARATION
I hereby aRnn that I am exempt from she Contractor's License Law for the
fallowing mason. (Section 703 id, Business and Profusluns Cade: Any city our county
which requires a permit to construct. alter. Improve, demolish, Of rAPAir any structure
prior to its Issuance, also requires the applicant for such permit to fit" signed ,W Wment
Sq. Ft. Floor Area V
Valuation
Lathe is licensed pursuant in use provisions of the C
$511159
that he is exmmpt therefrom and the basis for the alleged exemption. My violati on of
AFN Number O
Occupancy Type
Section 7031.5 by any appliumfar a permit subjects the applicant W a civil Penalty of A
trot mom Nan Rve hand" dollana ($500).
❑ 1, as owner of the prepcny, our my employees with wages u their mW compensation,
Required Inspections
will do the work and the.bucdum isnotmmMedaroBered foruk(Sm. 7040, Business R
and Prefe lions Cade: The Contractor. License taw does sat apply W an owner of q
q P
proputy who builds or improves Neaten, and who dues ouch wart himself or through his
awn employes, provided that such imPrewoents are not Intended arse @red for VIA. If.
however, the building or Improvement Is sold within one year of completion, the awnar.
builder will have the burden of proving that he did not build or improve for purpose of
oak.).
❑ 1, u . of the property, am eaclusivcly cmuacdot with licensed contracbn W
construct the project (Sec. 7014, Business and Protections Cade:) The ContncWrs Li.
cause Law does not apply W an owner of propen,who builds our improve demon. and
who contracts for such projects with a tom Vior(s) licensed pursuant W the Contractors
License Law.
❑ lameaemptunderset .Bk PCfor Nisreamn
Owner Dane
WORKER'S COMPENSATION DECLARATION
1 hereby afros under penalty of perjury Are of the following declarations:
1 haw and will mainuln a CeniOuW of Contemn to self -WSurt for Workers ComPan-
ssdan, ea provided for by Sudan 3700 of the Labor Code, far the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Wolters Compensation Insurance, As required by Section
3700 of the Labor Coda. for Ne performance of the work for which this Permit Is Issued.
My Worker, Compensation Inuuanae carrier and Policy number are:
Cartier•.'19�� �liLt� -{'� Pal4T No.: La l G
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Mks section need not becorepleWd If the panel, is forove hundmddollars ($100)
m less)
1 unify that In the perf des nce of the work for which this permit is leaved, I shall not
employ any person in any manner w u W becomesubjecua the Worken'Compemation
Laws of Cstifom)a. Data
Applicant
NOTICE TO APPLICANT. If. afer making this Certificate of Exemption, you should
became subject un de Worker. CA.Nmdan provisions of the Iahar Code, you a.