05020123 (2) CITY OF CUPERTINOs` WIFE a "
BUILDING DIVISION PERMIT ,CONT1tACTORms�INFO1iMATIQN
BUILDING ADDRESS: PERMIT NO,5 0 2 012 3
NER'S NAME: PERMIT ISSUE DATE
LEE ' S SANDWICHMq NE: SANITARY N0. CONTROL N0.
ARCHITECVENGINEER: BURRING PERMIT INFO
BLDG EO PLUMS MEOCH
ilOGLICENSEDCONTRACTOR'S DECLARATION lob Description
1 bereby turns,that I am licensed under povmmei
islmse of Chapter 9(cemng
with Stt0on7IX )of Divisiin7af Budnessand Professiuna Code,end ylrcenmu
j� I.full f.=andcue SIGN
Z Licemc Cl s Lic.,
t� Dela conMatter CONTRACTOR: LUCKY SIGNS
I�Q CHRECI'S DECLARATIO ��- ///
'� tyi 1 undemand my Plan+eMll be used u puMlic records �J � ,
Licensed Professional
5 Met I am exempt fr mDECLARATION
R�9 I he .(B on 11. .exempt from the Cssions ru License Law for nw /
Ra O following won.permit
i IIommu Buircss and no.de im6 Cade:Any oily or roomy
$�i which mqulme•permit ea conaean.Blur,wpmw.demolish.or repair any structure
1- 12 prior m ill issuance,also requires the applicant for each permit to Ne a signed summons
{qsbFp< Met he is licensed pursuant to the pmvisions of de Contrsemri lJttrvm Law(Chapter 9 Sq,Ft.Floor Area Valua O�1900
63S (commencing with Section 7000)of Division 3 of Me Business and Promealons Code)or
3 thin W is exempt Motorman and the basis for Ne alleged eampdan.My violation of
Scetion 7031.3 by airy applicant fm a permit objects the applicant m a civil penalty of ApN Number Occas ane
nil mom sun Rw bd
ured dollsrs(5300). (Occupancy Type
rc
❑I,u iwrofthe,property,army employees with wages astheuealecompenuit 31626090 . 00 m
willdo the work,and the sommure isnot intended oro@red forrom(Sec.7044,Business Required Inspections
and Professlim cto
Cede:The Conmr's License Law does not apply in an owner of q p
propertywha builds orimpmws Neeson,and whodoessueh work himmlfar through his
owes emplay=,pmNded that such improwmanu are nom Intended oroaered fm ssm.If.
however.Ne building or improw:menm is sold within oro year of completion,the owher-
builder .will hew the Wrden of proving that he did not build or improv,for purpose of
um.).
0 1,as owner of Ne property,am exclusively contracting with licensed conoeamrs to
,mussel the pmject(Sec.7044.Business and Profession Code:)The Contractor's U.
cause Law dos out apply in an owner of property who builds or impmwa Neeson.and,
who concocts fon such projeeu with a con ractor(O licensed pursuant m Ne Contractors
License Law.
0 1 sm exempt under Sec. .B&P C for this mason
rcr
Data
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of Ne following declmillom: '
1 hew and will mumu].a Cerdbcam ofConmm la self-Imam for Worker.Campen-
union,u provided for by Section 7700 of dm Later Code,for Ne performance of the
work far which this permit is mount.
0 I haw and will maintain Workers Compensation Imurua.u required by Section
77W of the Labor Code,for the performance of the work for which this permit is]mud.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMFOON FROM WORKERS'
COMPENSATION INSURANCE
Mlit section need not he completed If the rcrmil Is formic hundred dollars($1110)
or less.)
1 certify that In the performance if Ne work for which this permit is issued.I shell not
employ anypeuon in any tun s sal 'act to
the Wo&ers Compen.atIon
Laws of California.Dam
Applicant L
NOTICE TO APPLICANT.lf�rffer making this Certificate of Exemption,you should
baame subject m the Worker's Compensation provisions of site Labor Code,you mum
.JO fiMwith comply with such provisions or this permit Nall w almond rnwkd.
z v~y., CONSTRUCTION LENDING AGENCY
I-a I hereby alrum that More is a construction lending agency for theperfmmance or
fYi the work for which this permit is issued(Sm:.3097,Civ.C.)
LQ Lender's Nene
.`T. z Lenders Address
U0 I ceNfy that 1 low mad this applicamm and sus Nat the above infmmudun is
I4 ^! correct.I agree to comply with all city and county ordinances and sum laws mining m
0 building construction,and thereby authodm mpmaenutiws of this city to cnwr upon the
W above-mentiored property for Impaction purposes
LL (We)agree in ass,immunity and keep harmless the City of Cupertino.gout
rp liabilities,judimenu.cow and expenses which may in my way scan,against gold City
U 7 ineomax, of dreg ting of Nu permit.
F7 APPLICANT UNDE ANDS A/ffffy��p WILL COMPLY WITH A4L NON-POINT Issued by:91tvaRf_ Date
SOURCE R"11 S. LQf Z//7/0�
Qf A f Re-roofs
Signature of Appliean onoaetorData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or to=building oaupantpore in handle hauNous material
as de0ncd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
o
ut.Section 37333(a)7 All roofs shall be inspected prior to any roofing material being installed.
0 Yes 839.
Will Ne applicant or future wilding occupant ern equipment m dcrices which If a roof is installed without first obtaining an inspection,I agree to remove
l hauudnu air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
wict7
0Yes t9 u
I haw read dse hvaNlmsmacriabrequlremcns undr Ompmr 6.93of the C.liror,
Hex Sid c ,Smvmu73703.33377 ax1337J4.l unhrsund Nnif Nc wilding
u mol currently Im tanmI u u my responsibility m notify Na aceupanl of the
ulrem h twmet ' rmissuanceoraCertilkateof span, Signature of Applicant Date
Owner or suthom<d Agent L � b� All roof coverings to be Class"B"or better