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05020123 CITY OF CUPERTINO BUILDING DIVISION PERI' ION xwvd�dt. '}' �z'rR,'XA' a+w hSbs wisO via BUILDING ADDRESS: "'B"T Nfb S 0 2 012 3 ER'S NAME:15 PP.IaMIT LSSl1H DATE LEE ' S SANDWICHES SANITARY 040. CONTROL NO. PHONE: ABUILDING PERMIT INFO RCHITECT/ENGINEER: BLDG ELECT PLUMB MECH p 0 0 +aOp LICENSED CONTRACTOR'S DECLARATION Job Description a�F 1 hereby affirm Nat I am licensed under provisions of Chapter 9(commencing ,ZZ with Section 7")of Division 3 ofee Business and ProfessionsCode.and Yho.sucts t in full Looe and eff ELI R Lleanu Ma. Lie.N —7g 6 r SIGN Doth Contractor CONTRACTOR: LUCKY SIGNS q CHfrECrS DECLARA�TIOI,, LL"`"-°' t I underxand my plans shall he used As public retards DU ;o Licensed Professional OWNER-BUILDER DECLARATION I hereby affirm Out 1 1. ,Bumps Imre On Conuanmrs Any C Law for the S O which Ou reason.(Section 703L5,Business and ..de arm Code:Any city or county u�$ which mquira a email 1.ac amts;On alter,Impmw,demolish,or c a sig any structure Fly pool mireienanro,asuamyoireahovppucaofinewonP,rmamfneaeiAmstatement Value G isthat heiacingwiit pursuant h)provisions nf.f .the B..in., r;cevclsicow0pm9 Sq.Ft. Floor Area �°l'900 $ isromancingSereion70o0)the hubfor the theeged exempt.rd Professions Cndc)of Nes he ts exempt ihemrrom and the beers far the alleged exemption.10 Any it Pen toy of Sccdon 7031.5 by any applicant(or a persalt objects the Applicant to a civil penalty of ppN Number Occupancy Type not mom than raw hundred dollars(SSW). 31626090 . 00 ❑I,u owner of the property,m my cm atersd s coo wage.formic their rete 044.B sin. and Pr the work.Codec he Co eiasues Lt dud erawdo amapply 7t1.In momeas Required Inspe s and Professions Code:The Consrsemn,Luno law eon nos apply to an rough Of is q P Property who build.mimpratu thereon,and wbo Am nota h wnrkhim¢If or cough his / howemployeuildin i or Improvement such It Improvements Am not yes,or euraffered theaale. t- however.the building oren ofrovinghal he not yens of completion,eeownen Rbander will naw th Wren proving wt h am not area or missive far pusposs,of .ale.). 0 I,as Owner of the property.am exclusively contracting with licensed Contractors la O�\ conswct the pmjen(See.70044,Business Cad Professions Code:)The ComuacwYs Li. cense law does oat apply m an owner of property who builds or improv.human-and, who Cmgmcu for such projects with a eontsmtor(s)licensed pursuant to the Commesoes License Law. 0 l am exempt under Sec .B A P C far this meson One, Data WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penury of perjury one of the following declantlo ce 0 1 hire and will mainmin aCertificamaf Consent to ml6insum for WorkersCompcn- mdan,As provided for by Session 3700 of the lAbor Code,for On performance of the work for which this permit is issued. ' 0 1 have and will maintain Works"Compensation Insurance,As required by Section 37000 the Labor Code,for the performance of dm work for which this permit H Issued. My Workers Compensation Insurance artier and Policy number am: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This sectio need not necompheml if the Permit Is forme hushed dollars 4100) or 1usJ I certify Oat in the performance of the work for which this permit Is lowed.1 shall at cmplganypersoninany mann s > c&p ore 'CoUoths N Workcrs'Compmson Laws.(California.Dem Applicant NOTICE TO APPLICANT:If, cr making ON Certificate of Exemption,you should became subject to the Worker's Camper hm provisions of the labor Coda,you must .7. O forthwith comply with such provisions or this permit shall be restated mvaked. Z^ CONSTRUCTION LENDING AGENCY 1-t l hereby affirm that them is a constnmtion lending agency far the performance of C . the work fur which this permit is issued(Sec 3097,Civ.C.) W Q Lenders Name ]Z Lamee.Address U Q 1 Certify Oat 1 haw mad this application and state eat the&bon information is {P.F cancer I agree la comply with all city and county ordinances and sum laws mining An QU building construction,and hereby unhodan representatives of tha city to came upon the W shove-memometl properly for inspection purposes. gy (We)agree to save,indemnify and kap harmless the City of Cupertino against cn liabilities,judgments,costs and examen,which may in any way scene,a gates.mid City Uz in consequence of the of ti ng of this permit. �+ APPLICANT UNDE WANDS A WILL COMPLY WITH ALL NON.POINT Issued by: Date SOURCER AT S. A, Z- 21016"10" Re-roofs Signawrc of Applimn Lonuactor Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof WIII the applicant or future building aecupmt uom or handle hazardous matsdal As di by On Cupertino Municipal Cock.Chapter 9.12,and.he Hula and Safety rode,Section 25532(1)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yes ®'Nu Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove cm 11 hazardous air contaminants As defind by the Bay Area Air Quality Management all new materials for inspection. District? 0Yes t I have mad the hmrdims mamdalsmquirements under Chapter6.95 of the Califon ria Health&Safety Cade.Sced...25505.25533 and 25534,1 understand thnif the building dote oat currently ho tenant ens it u my eespubsibility m notify the occupant of Oe mquimmcnWinlfh Brest crtaixuxmC.fa Cemratnaf up"/ Signature ofApplicant Date Owner or authorized.,at 7 p�' All roof coverings to be Class"B"or better (n 3 S � LJJLu w m °^ 0 M Q ® z a ' z D Qe �1 A R y 1 its LLJ on � � Q z �03 'L N _ • P Ln 0 cli zo i 1ti � W Um � � W µ r a% d 'pop" Pkid::,`g w J J 04 UJ Z '- QZQ N U m N E. y N 0 . i ! ! � ~ .TZ L OL U) 2 | ( L � ° § � / / � 3 � Cl) 0 : % \ - ° \ ) 2 / } \ E k 7 \ E \ / ( ! uj m c / 3 CL \ \ r >� A mE6I = � . 2 ] 2 � \ E 7 Zo c 6 � 5 '0 m § zo \ ' � ~ \ 2 \ { / m % . . Q :um t \ � © a . \ ! �. \ Lu Lu gC 2 � \ f ( 04 10