05030328 CITY OF CUPERTINO r;k�U.v O�k}rJysa4,rV*
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS: PERMIT N0.
JUST CONSTRUCTION 05030328
eRREfE AM PERMITI.SSUEDA7E
E; SANITARY OL NO.
ARCHITECDENGINEEK: BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
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29i] LICENSED CONMACIOR'S DECLARATION lob Description
M❑< 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
with Section? M))o(DIAndon 3or Me Businessand Profession.Code,and my license I.
in full force and effect. 9/.�
yqz ucemunClar. Lm.x Y_�_q �_ TI-INSTALLATION f LEEN�OLAS
t:a DBm Co.,. r
ARCHITECTS DECLARATION RETAIL STORE
I mndenlenJ my pima shall he used u publmbOc nec Accords
cad Licensed Professional 2005
OWNER-BUILDER DECLARATION
1 hereby affirm Thal I am exempt from the Cantn tors License Law for the
O O following mason.section 7031.5.Business and Professl0u Code:Any city or county
B which mqulms a Permit to annatruct.elm,.improve,demolish.m repair any nmclure
14h2 prior m its issuance,alw MARAms the applicant for such Permit file a signed atammenl
that he is licensed pursuant to the previsions of the Comrumri Lt<nse Law(Chapter 9 Sq.Ft. Floor Area Valu Lb
(commencing with Section 7")of Division 3 of the Bualm,s and Proreuions Code)or Y c+�0 0 0
that M in exempt Muchrom and de bash for she alleged exemption.Any violadan of
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of AIYN Number Occupancy Type
not moan than five hundred dollars(M).
❑1.As owner of the propeny,in my employees wish unto udeir sok compenation, 35908018 . 00
will do the work.and she wucmm lmotimended or offered for safe(Sm.70".Busircu Required Inspections
and Profeaiona Committees The Conttees Licerue it. wn
Law w t apply m an owner of q P
property who build,or Improw,tie ism.and whodocssuch work himmiforduoughhis
Own employees,provided shauuch improvements are nolinmMed oraffertd for Ws.IL
however,she building or improvement Is sold within am year of completion,she most.
builder will have the burden of proving that M did not build or Improve for purpose of
late.).
❑1,as owner of the propeny,am exclusively contracting with licensed comramn to
construct the project(Sec,70th,Business and Profession Code)The Contrsetm's U-
cense Law does not apply m an owner of propeny,who build,or improves Memon,and,
who contracts for such projects with a contrmmr(G licensed pursuant in she Convenors
License law,
❑1 am exempt under Sec. .B d P C for this rcuon
Owner Date
WORKER'S COMPENSATION DECLARATION
AI firm
1 hereby afunder Penally of perjury ore of the following deelaa0ona:
haw and will maintain a Cenificam of Consent to self-Insure fm WorkersCmnpen-
utlon,u provided for by Section 31M or the labor Code,for the pedarmmce of Ne
work for which Nis permit is lamed.
❑I have and will maintain WerkeM1 Compensation Insurance,As Acquired by Section
3700 of Ne Labor Code,for Ne performance of tie work for which this remail is issued.
My Worker,Compensation Insurance carrier and Policy number art:
Cartier. APolicy No.:sf K6MON MOM WO�RK!P n
'
COMPENSATION INSURANCE
(Thin Mellon need not becomplemd if the permit is froom hundred dollara4I00)
or less.
1 sentry shot in she performance or the work for which this permit is Issued,I,hell not
employ any person in any manner an in to hecOme subject a the Workca'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,afar making Nis Certificate of Exemption,you Mould
become subject to the Worker's Compensation provisions of the labor Cod,you muss
.JO forthwith comply with such previsions m this permit shall be dcemed reveled.
5; CONSTRUCTION LENDING AGENCY
�—t I hereby affirm that them Is a constmctinn lending,Semy,far the performance of ..
ai Ne work for which this permit is issued(Sec.3097.M.C.)
W Q Lender's Name
Q z lender's Address
[)Q 1 cenlfy shat I haw read Oil, pplication and Nm that she alien Information Is
W 6+ correa'L l tame to comply with all city and county ordinance,and sum laws mining to
Q C.7 building croswction,and hereby authodm representatives of Nis city to enter upon the
W above-mentioned properly for lnspecdon Purpose,.
fy...r
(We)agree to new,indemnify and keep lormlea the City of Cupenino against
f-t rrAA liabilities.judgments,cuts and expense,which may In my my accrue against mid City
V In�+ APPLICANTA
OUN Uof the NDERSTANDS of IND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOUR ERECULATIO
Re-roofs
Signatu o Appliean omrtm Dam'
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or future building k,Chari nore2,and t c Health an maeriai
As defined by tit Cupenlnn Municipal Code,ChaPmr 9.17,and the Hetlsh and Safety
Cwe.smtion35532(a)7 / All roofs shall be inspected prior to any roofing material being installed.
❑Yo QNu
WIII the applicant or future building mcupant um equipment or Device,which If a roof is installed without first obtaining an inspection,I agree to remove
t haurdnu air contaminants as defined by she Bay Area Air Quality Management all new materials for inspection.
District4 ��r
❑Yo ydTm
I hew read she huuthma materials Acquirements underChap er 6.95 of the Califar.
nlaHolm.k Ssfety CWd,Sec:dons35505,75533ud35534.1undcnund thatiftie huildlnt
dues nm curtendy haw a mmol,Net It Is my rcamnalbllhy to mdl'y the Occupant or
Mqu menuwhmhmust IMmet prior toissuance ofaCeriOcamofOccuprmy. Ign tureofApplicant Date
waer nr anal soloed. ant " Dam` All roof coverings to be Class"B"or better