05040021CITY OF CUPERTINO
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CONTRACT,URANFUR ATI0R1
BUILDING DIVISION PERMIT
BUIIAING ADDRESS:
PETS MART
PERMIT '005040021
OWNER'S NAME:
PP.T,q MART
PERMIT ISSUE DATE
E:
SANITARY OL NO,
ARCHITECf/ENCINEER:
BUILDING PERMIT INFO
ll ELECT PLUMS MEACH
O O O O
LICENSED CONTRACTOR'S DECLARATION
Job Descri tion
P
Chapter 9 (cemencins
1 hereby mom Thal 1 Am licensed under provisions of Cham
wish Sadon70f10)of DivWoo3oflk Buri wvWfro/_ mC9deren,�y lice.is
in fun fora and eifua/1 446, Zr%d �`J'�
C.7
DEMO (INTER. )
uc"A" CI Lk. V.
Date cs ——Ouomm°r
CONTRACTOR: S.T. BAGGETT, INC
ARCHITECTS DECLARATION
1 understand my plans shell be used u public reconts
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby ^rcrm it I am exempt from the Comraerers License Law for the
following moon. (Section 7071.3. Business And Prones ou Code: My city Or county
which mquirn a perms, to courtroom, alms Improve, demolish• or mpaIr my summers
prior to its issuance. alw requires the applicant for such puri, to file a signed suement
Nal m is licensed pursuant to he provisions of the Convectors Law w (Chapter 9
Sq. Ft. Floor Area ValUa 0 0 0
(oommencin{ with Section 7000) of Division 3 of Nc Business, and professions Code) or
,
Coat he Is exempt temfrom And We basis for the alleged exemption. My violation of
APN Num Occupancy Type
Section 7031.5 by Any Applicul, for a permit anbjeeta Ne APPlicant to a civil Penalty of
not mom Wn five hundred dollars ($7007.
❑ 1, As owner oftke property, Or my employee wit wages As their me, computation.
35908018.
willdo the work, and Ne sssactme Is notintenmcd oronered fersWe (Sea 7111 Business
C Ons
and ProfesaloCode: The Conumtors Lice. Law dors ml apply to An owner of
u
does his
--41Req
property who Wild, orimproves Chem^n. And who smhworkhimselfmthrough
provided such lmprovemanlein not ded fm
Own employces.Am
C h�
year of manor,
,the WI or improvemantg mid within oue you or mpro a for Ne owner-
pt
bueder will have Ne burden of proving Wt he did trot build m improve (m pupae of
Witter ban
Q®
ole.).
❑ 1, as names of the property. am exclusively contrmtin{ with BCoued contrA CAA to
mmmuc, the pmjm (Sec, 7044, Burmese and Profeaou Code:) 7m Commutes Li-
Come Law does not apply to an owner of pmpeny who builds or improves shorten, and,
pN!`_a��Jvne
with a conuactor(s) Iiceed puma, Conuactoes
who contracts for ck projects uma, to t
sli
Lkenee 4w.
❑ I am asempt under Sm. , B h P C for tis moon
Owner Dee
WORKER'S COMPENSATION DECLARATION
I Washy alum under penalty of perjury oro of Ce following declaration:
w and will maintain aCeNOcae of Covent to self-iuum for Workers Compct.
n, as provided for by Section 370E of the Labor Code. for Nc pertonmurs of to
wick for which Nis permit is issued.
❑ 1 have and will maintain Woftes Compensation lumuut, As Mquined by Section
3700 of the labor Cmi for Can perfermuec of to work Ter which Nis Pemi, is lamad.
ber
My Worker Insurance Inrance carrier and Policy number am;
Carrier: �T�7C Cc�Actf� PPolicyNo.IGgm�
CERTIFICATE OF EMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This section need not be completed If the permit Isforcm hundred dollars ($100)
or len.)
1 unify but in the performance of the work for which this permit is issued, l she not
employ any person in my Counter an As N become subject to to Workers' Compe=Uon
I.A. of CAlifomia. Dau
Applicant
NOTICE TO APPLICANT: If, after making Nu Ceni0ate of Exemption. you should
become subject to to Worker's Compensation provisions of to labor Code, you mol
forthwith comply wit such provisions or Nis Permit shall be deemed mvoked.
1
CONSTRUCTION LENDING AGENCY
I hemhy aMm Nal them las construction lending agency for to perfumence of
i tiM work for which this permit is issued (Sec. 3097. Civ. C.)
Lenders Nme
lenders Address
1 aNfy that I have read this application and suss Nm Ne above infommice U
' comet. I spec to comply with All city and county Ordinances and sou laws Mian{ to
Wilding construction. And hereby authoden mprsa mom of this city to enter upon the
shave-mendoned property for impeaon purposes.
(We) Agree an save, indemnify and keep hamlaas to City of Ctipenino Moral
i imbilWeAjudgments,cots andexp^ecce which may in any way accue apimt aid City
In conseguenCo of Ne {MOn{ of tis pcmit.
I APPLICANT U DERSTAN9S AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURC
Re-roofs
SiSi{nu ofA licanVCommoter Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will to applicant or for= Wilding mcupanarem, m handle hazardous material
As de0ued by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
cede. Semen :ss3:ta)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yec ,�
If a roof is installed without first obtaining an inspection, I agree to remove
Will to applicant a future wilding Occupant can equipment or devices which
ha'rumou It communanm u dc0ned by to Bay Area Air Quality Msnagemenl
all new materials for inspection.
ria?
❑Ya
1 have mad the humnlous materials mqui mments undo r Chaper 6.93 of the Cali fnf-
10—.n.r
OO tlkS r ty Cede, Scctiou 37705.25533 and25534. 1undemmod te,ifthc wilding
not currently haw A tenant. but It u my responsibility to nudity the occupant of Ne
lumcnu which Monet priortoissuanCo ofa CeNfualeel Occupancy.
Signature of Applicant Date
j4 l -0
All roof coverings to be Class "B" or better
er. edued. em Date