04050157 CITY OF CUPERTINO a"' '€:'=
BUILDING DIVISION PERMIT anEONTRACTORINFORMATION
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BUILDING ADDRESS: REEVE KNIGHT CONSTRUCTION PERMITNo04050157
OWNER'S NAME: PERMIT ISSUE DATE
E:
SANITARY 907ROL NO.
79�
ITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATIONJobDesc 1
I hereby affirm Nu I am Iimmed under pmvisiom of Chapter 9 mommnu:ingALED
ceuon )ofDivision3 of the Businpsmd Professions Code.and my license is^ ( dctt,ct� ✓ fIi �t✓zG �cN^"�m6 d- yTI--RESTAURANT OCT�7 ?OO4
££ ^`1` ARCHITECTS E LARATION
C i 1..&.nd my pias shall he used mcarda
DaV
=o Licensed Protectionist
rt BUILDING
g OWNER-BUILDER DECLARATION
I I hereby affirm Net 1 ons exempt from the Contras oar License Lew for the
p o following reason.(Scctiud 71D l.0.Business and improve.
dmio li Cod,:Any city or roomy
m which rt9uirea a permit re requires
the alter.impmsu demolish,car repair any tatement
poor m its issuance,aim mqo do,the applicant for such rector'm Glc License signed summem
to that heirlicenseitpusstion7 the ofProvisions ionfthe eBuiness nProrlaw(C Code)Or Sq.Ft. Floor Area - Valuation
6 $ (commencing with Section 7")of Division)of the Business and Pmfm¢iena Code)of
Out he Is exempt therefrom and the baso for the alleged exemption.Any violation of
Section 7071.5 by any applicant fon Permit subjects the applicant o a civil penalty of APN Number Oeeu ane
not mom than five hundred dollars(SiSM). P Y TYPe
,
Q I,mown of the prapc^y^r my employees with wages as their sole compensation,
will do the work.and theswmure is net intended buffered for sale(Sec.7044,Business9080 8 . 00 Required Inspections
and Professions Code:The Contractors License Law does not apply to an owner of e q p
property who builds or improves thereon,and who does such work himself or through his
own employee,provided that such improvements ase not intended or offered for sale.If.
however,Ne building or improvemens is sold within ons year of cemplat Ne ower,-
builder will have the burden of proving that he did not build or improve for purpose of
salt.).
❑1,as owner of the property,am cmlusiwly contracting with licensed convectors to ,
consumer the pmject(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law docs not apply to an own of property who builds or impmws Neaten,and,
who contracts for such projects with acontractoris)licensed pursuant o the Contractors
License law.
Cl 1 am exempt under So. ,B h P C far this...a
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a Cerdficam of Consent self-insure for Worker'sCompcn-
137W
n,as provided for by Section 7700 of the Labor Code,for the perfom mance of the
for which this permit is issued.
have and will maintain Workers Compensation Inumance,as squired by Section
of Om labor Code,for the performance of the work for which this permit is issuedWorker'Compenaaden llnsunyce carrier and Policy num ram:m'. 1LCt FtYVIL/f Polity Na I�
CERTIFICATE OF EXEMPTIONORKERS'
COMPENSATION INSUR NCE
Obus secfre m,m]not recomputed if the Permit is 17.1mucl a rdrod dollars(SIM)
or less.)
1 certify that in the performance of Is work for which this permit is issued,1 stroll net
employ any person in any manner se as to hecomc subject to the Workers'Comp,mation
laws of California.Data
Apialitmnt
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions or the labor Code,you must
JO forthwith comply with such previsions at this permit shall he deemed revoked.
P(7 CONSTRUCTION LENDING AGENCY
(~ Iheatby oform that then is a communion lendings for the fureantt of
Oa work for which thin .) per
FL permit is issued(Sec.)097,Civ.C.1
QLenders Name
D z Lenders Address
V O 1 comly that 1 hale read this application and cute that the show information u '
Fcommit.I agree in comply with all city and county oNtnan es and sue laws relating in
building construction,and hereby and orim mpreamutims of this city in enter upon on,
a shove-mentioned property for inspection purposes.
(We)agree to saw,indemnify and keep harmless too the City of Cupertino!garnet
Fro Ilabililies.Judgments,costs and expanses which may in anyway accrue against avid Ctry
of the
LJ z APP ILCANTeUNDERSTANDS Aandia,of ND WILL WILL COMPLY A NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
OnIicanUCmn ter Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant More or handle haretdous material
as defined by the Cupenim Municipal Code,Chapter 9.12,and Ore Health and Safety
Cade,Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
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
,harmdousair contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
,sure(?
❑Yes IQT7m
I have mad the haaaN,us materials mquirements under Chapter 6.95 of the Calilm-
meHealth RSaf,tyCodc.Saduro 25505,255))and 25534.1 undcrsuM door if the Wilding
does rot currently have a tenant.Nu it u my mspeasihility in notify the aveupant or Ne
ray mm tlwhichmustkme(pdormissuany�afaceoff, ,aroecepan,y. Signature of Applicant Date /
Date All roof coverings to be Class "B" or better
w�ncr u�hari'red a t g