04060016 CITY OF CUPERTINO "^"'•rte x i`
BUILDING DIVISION PERMIT 0 R.�TTd I''�I'M, z'[a Ohl, '
BUILDING ADDRESS: """'004060016
ERMITNOO4060016
OWNER'S NAME: PERMIT k99UE DATE
Ad IL STARBU K
E; SANITARY NO. 9 CONTROL NO.
lip
ARCHITECT(ENGTNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u0o LICENSED CONTRACTOR'S DECLARATION Job Description
eg V 1 Wreby affirm that 1 am licensed under provisions of Chapter 9(commencing
miles ect'an]aM])af Diviaio Jof NC Businm aM ProfeWons Code end mylkensc ie
a� mmnmaamerce 'j 3� NSTALL COLD BEVERAGE STATION
n�� Lice wcso. Lk.p
Dam o c.atmmr & RELOCATE FLOOR SINK.
ARCHITECTS DELLA ION
1 understand my phosmall he used as public records CONTRACTOR-WESTERN CONSTRUCTION PD 5/27/04
DyU
G N Licensed Pmfessionel
s OWNER-BUILDER DECLARATION
f I thereby+(Sere that 1 am1. uempt from d r Convector's License Law for the
OO
Following reason.Permit
](BIS,Buafer. and Professions Code:Any tiny or county
5$ which its a issuance.permit re cores the alter,impma,demolish,or repair ed avucturc
priormitssedpurse pursuant
he theapplicant offor Inch pennitm Gln.Lawdsutement
££S
that
ommencansedpurstion7thcprovivioaofthe ortooBtmcmhndprefcaresCodmr9 Sq.Ft.Floor Area Valuation
(commencing therefrom
and w bonds
m al egad co apt prefectures virCade)or
that he u eumpt therefrom end we bats for Ne alleged eumpnon.Any violation of $28000
Section 7031.5 by arty applicant for a permit subjects the applicant in a civil penally of APN Number Occupancy Type
nut mare Nan foe hundred dollars($500).
❑1,nownerof Okpmpmy,ormyemploycmwiMmgau Nairsolacompenadon,
ill do the work end me,structure is mathematical morremd forsale(Sec.7041,Business
and Professions Code:The Condolences License Law dam not apply m an owner of Required IDSpecti
property who buildsorImp rvmthereon,endwha doessuch work himsalfor through his
Me
q
awn employers,provided Nat such improvements an,maimurWed orottered forssle.It. /�S
however.we building or improvement is said within one year of eampletion,we owner
builder will have the budden of proving Nan k did act Wild or Improve for purpose of V
❑1,as owner of th,property,am exclusively connecting with licensed eontnctars in 99
come La the project(Sec.7W,ownBuser
of and Profusions or
The s dud on, Li-
eeae law does not apply m an owner of property who Wilds por improves thereon,and 7
whoa.Lace for such projects with a eonuumgq licensed pursuant m Or Communes
Liccnu tsw.
❑Ism mempt under See. ,BdePC Tar phis revon
Owner Dam
AOL WORKER'S COMPENSATION DECLARATION
1 hereby affirm under ,penalty of par ane of we following declaetioa:
eve and will meintsin a CeAGam of Convent meelf-iaum for Warkcr'sCompcn-
snion,a provided for by Section 3700 of the ItWr Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,a required by Section
3700 of the labor Code,for the performance of the work for which this permit is isswd.
My Worker's Compensation lnsurre c�Polie.y,
number am:
Cartier. T�FIOF EXEMPTION
FROM WORKERS'
COMPENSATION INSURANCE
(This section need not k comple ted if the permit winters hundred dollars($100)
or las.)
I cenify Nat in me performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject o the Workers'Compensation
Laws of Califamia.Date
Applicant
NOTICE TO APPLICANT:IL after making this Coalfieate of Examption,you should
become subject in me Worker's Compensation provisions of the labor Cook,you must
0z forthwith comply with such provisions or this permit shall k deemed revoked.
ti 0 CONSTRUCTION LENDING AGENCY
a
Fr I hereby affirm that there is a construction lending agency for the performance of
W' me work for which this permit is issued(Sec.3097,Ci,C.)
W0 Lenders Name
CL zLcnder'a Andrea
U 0 - 1 cenify Nn I have reed Nis application and sum than me above information is
VL Pcancel I agree in comply with all city and county onammas and sum laws misting to
O building canstrouction,and hereby aunhorm ormsamadvas of this city to motor upon the
0 W abovomemioned property for Inspection purposes.
V
(We)agme to save,indemnify and keep homeless the Cit,of Cupertino against
H liabilities,judgments,costs and expenses which may in any way see=against sold City
U Z in consequence of Ne grating of this permit.
.. APPLIC NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:3 Date
SOU GULATIO
t Rd-roofs J
Srg u' rg pplia r�/i ConRDO Dem
HAZARDOUS Mding o DISCLOSURE Type Of Roof
Will tisc applicant or future Wilding cecupentstore or handle haallous material
a defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
ad,..Section 25532m)? All roofs shall be inspected nor to an roofing material beim
❑Yea ON.
P P Y g g installed.
Will the applicant or return building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hnaam us air conmmirums se turned by the Bay Arca At,Quality Managcmcnt all new materials for inspection.
-diet?
❑Yes ON.
I have mad the hasulausnommils requirements under Chapter6.95 of the Califon
.is Health&SafctyCmw,Sections25505,25533 and 25534,1 understand thwif NO Wilding
Jars n curtcntI have a morns,that it Is my responsibility an notify Ine occupant of the
rcy ' ems which mark Ipnorwissuanceofa CcnlGcateof Occupency. Signature Of Applicant Date
weer ounce vndagen �' D m�0 All roof coverings to be Class"B"or better