04060259 CITY OF CUPERTINO77.,T5. 1V1 �, _�
I1 Bmhomc DIVISION PERMIT TR
CONACTOR INFa TION s '
r1l BUILDING ADDRESS: PERMITN
MCLARNEY CONSTRUCTION I04060259
OW488 STEVENS CRT< 4 2010
NER'S NAME: PERMIT ISSUE DATE
LE BOULANGER RESTAURANT SANITARY NO. - CONTROL NO.
E:
4082468600
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 0 0
li o p LICENSED CONTRACTOR'S DECLARATION -
1 lacratry affirm that 1 am lianscd tuaSyrovisrones of Chapter 9(commencing Job Description
With Se 7,01111)of Division 3 of NC Bur and Professions Code,and my licento is
ONK
or nderfea` �L ucx lfg6 REVISION--FIRE CAULKING DETAIL
zo yam° oraL�,.
contractor r NO NEW PERMIT ISSUED/ORIG. 404010077
'–�4 —b1•�–r
ARCHITECT'S R non
a d I unticrsmnd my plans shell he used u puElic rccnrN
O�
o Licensed Professional
g OWNER-BUILDER DECLARATION
<S 1 nanny affirm that 11. exempt from the Corrector's r'e UAny c Law for the
20 (.lowing reason. errant t RDLS, t,Business and Professions Credo:Any city or county
fi which requires a permit repo construct,the applialuer,cant
nt for such
hPermdemolieR m repair any statement
prior sir its issuance.also(equina the applicant for such permit m Ole signed ne.mem
< Ihat he is licensed pursuanua the pmvisionenfthe Committees License law(Chapter Sq.Ft.Floor Area Valuation$52
a�a�m (commencing with Smtion 7000)nf Division3uf NC Buairmss end Profcssians Cndc)ur
y that he Is exempt Ncrefrom and the bash for the alleged exemption.Any violation of
Suction 7031.5 by any applicant for a permit objects the applicant 10 a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
❑1,ssnwnmofthe property,ar my employees WlN wageutheirolu rompenssdon, 36901029 . 00
will do the work,and dee structure isnotinumand or offered forests(Sec.7014,Business
oil Professions Crude:The Cnmmcmr's Lt.Law does not apply.an owner of Required Inspections
property who builds or improves thereon,and who does such work throttler through his
own employees,provided thaloch improvements arc not intended oroRercd for sale.If.
however,the building or improvement is old within one year of complcdan,the trader.
builder will have the burden of proving that he did not build or improve for purpose of
cake
❑1,as owner of the properly,am exclusively conducting with licensed contractors o V
consdmet the project(Sec.7044,Business and Professions Cade:)The Contractara U.
who contracts
Law doer not apply m an owns of property who builds or improves Como.,and ,(�
who=Lacu forsuch proJecu with a eonbacmrts)licensed pursuant to the Convectors v r
Lice=Law.
❑lam exempt under Sec. ,B&PCfar this rcuon
Owner Data V
WORKER'S COMPENSATION DECLARATION
40I hereby nand under penalty of perjury ane of the following declarations:
mhave and will maintain a Cenifcate of Consent o self-insure for Worker's Centiliter-
it,as 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 Worker's Compensation Insurance,ss requited by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued
My Worker's Camp nu'on 1 situs an and Policy numbers 3
Came Policy No.: +
CERTIFICATE OF EXEMPTION FROM WOR S'
COMPENSATION INSURANCE
(Thhudi.need nor he completed Kine permit Is furore hundred dollars(SIM)
or less.)
1 ar ify that in me performance of the work for which this permit is issued,I shall not
employ any person in any manacr o as in become subject in the Wcrken'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to me Worker's Compensation prevision.of the labor Code.you must
�Q forthwith comply with such provisions or this permit shall be accrued revoked.
,ZiCONSTRUCTION LENDING AGENCY '
[-+ I hereby affirm dear there is a construction lending agency rnr the performance of
ai> Ne work for which this permit is issued(Sm.3097.Civ.C.)
QLender's Name
z Lender's Address
U Q 1 certify that I have mad this application and stem mat the above information is
H correct I agree o comply with all city and county eminences and one laws.].ting to
�U building construction,and hereby aumarim representatives of this city to enter upon me
above-mentioned prepcny for inspection purposes.
gL (We)agree to antra.indemnify ore keep hsrmless the City of Cupertino against
iE"y IA
led,Hu judg us us and ex nus which mayin anywayseeds against said City
V 2 in conuquen fthe gamingo his permit. _e r,
KPLIAND TAN AND WILL COMPLY WITH ALL NON-POINT Issued by: Date9? cs�
s. �6 0Re-roofslic HAlIARamm Datc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or future building e,Chapter
9.1 or handle Heamoun material
u defined by me Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(01 All roofs shall be inspected prior to any roofing material being installed.
0y. ❑No
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
t hazardous air contaminants as defrmd by the Bay Arca Air Quality Management all new materials for inspection.
aict7
❑yes 10No
shave read the annus in srcquiremcnu under Chapter 6.95 of ata Califor. .
nae Hral 4Safcty .Sccdons 255( ,25533 ore 25534,1 macround deazifthe Wilding
dors na
was, 04 ten t h my msp uibiliry m nodfy me mcupot of me
reqs' ma at omineanuoracertireatcoraeap`ry.,/ Signature of Applicant •Date
venton a sent Date � t/ All roof coverings to be Class "B" or better