01060061 CI nu of c oPv saioNNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
20770 STEVENS CREEK BLVD 01060061
OWNER'S NAME: APPLICATION SUB DATE
PAC PIZZA 06/12/2001
i PHONE: SANITARY NO. CONTROL NO.
I.
o m0 zo ARCHITECTIENGINEER: BUILDING PERMIT INFO
l F BLDG F,LECT PLUMB MECH
N<to C.J I' 1_I G.I
azJyn 1herebyoffirmNS
EhmEDmlicensed ONTRACrdR'Ppooreofinnpter9m°mmencins lob Description
ON_ce with Section 70001 i'DiNst 3 file BusinessaI P ss' �pe�nd icense
ad se S� is ca(at] rC ff Vl,r,_°f-C e7G CHANGE (RR) 200 METER PANEL & DISC 1
z i a 'Caense Clasp V Lic.p
.Date: Contmnor
3 y C Cf Cf'S DECLA l
FO S I undanend my plans shall be used as public records
ee as,
�Y
i ape C Licensed Professional
'L OWNER-BUILDER DECLARATION
=' I hereby affirm that I am exempt from the Contractor'%License Low for the
!-Fe a following reason.(Section 7031.5.Business and Professions Coda Any city or county
E x n which requires a permit to construct,alter,improve,demolish,or repair any swcture
yj ce 'Prior t.Its Illowse.all. q s h ca r.,o6ocnonro fl g d t enno,
thiala,ilfieposed, Ito ffie paq,kiaasoofmi,Cummainaye,Liclaw L (Chapter9 S FI. Floor•A1'Ca - , !,Lation
(eo a gwith Seo 70)01 of Division --3 I the Rosinsand lruk,,am Code) l f;'y s.;.�.y-r t}:y 1.1: S-_.. J. .a :! a.
or that he is exempt Ihemtrom and the basis for the alleged eaemphon.Any violation r
of Section 9031.9 by any applicant for a Permit subjeetx the applicant to a civil penalty- 3 5 9A �f H (PYO Occupancy YP
:of not a.Nan five hundred dollars(S500). Til f' Occn anC Type
❑I.as owner of the norm loses with woes as their sole core lion s
Pd to Y Y cmP Y g pcnsa
will nes the work,and the sry:Tre'Is not tra for s Li oreofferedLow for sale apply 7(}il.
Bus s dP rein Cod ThContractor t L L a I rkha n 304 - ROUGH ELf$L7�p�IQT e[ions�"
owner
fproperty nempl c p th and n work . Ir FINAL.-ELECTRICAL ENERGY _
r ih Ba h' ply provided th t h improvements t intended or .. 501_.
','Rin-df .'1 ITh thewilding-or p t Id within - ._. - a
y of : —construct
m rn 'la 'llh m h a fp gtlrth d'a toile or 50$ FINAL ELECTRICAL
n
rep o e for purpose of. 1 )
coL-av owner aforep pent' exclusivelycontractingitM1f A oompact m - . .. I --' 1 .� - "-
onswct the oes no(app Ito a Busowner and Profess ons Cada)The ContmcroT. .r �/
License Law does not apply mon owns of pmpcny who builds or improves s thenen.
p- > .and who matrons Wrsuch Protects.wiN.a.conrractmts)licensed pursuant to the
C License ISW.
❑I..am cle ucmpt under Scc.''_ _ ,B&PC 4x his reason
^ Owner Date
".:. WORKER'S COMPENSATION DECLARATION
1 hereby affirm under XmIty of perjury one of it following declarations.
O 1 have am will'maimain h'Cemm,we of'Cmount to self-i...m cot Worker's
Compensation, as for by Section 3900 of the Labor Cade, for the
performance of the work for which this permit is issuspi ,.
❑1 have and will maintain Worker's Comi&mswion Insurance.as required by Section
3700 of the Labor Calc,for the performewe of the work for which this permit is
" -
issued.MyWorker Compensation lnsumnce carr'r all Policy number are:"
Carrier:', :,ty l Palley No: 1 :.<_ sk, a k..,,(..,'ixJ a_.Id v.
CERTIFICATION OF EXEMPTION FROM WORK9R5't - -^ +� 3: , - -
gRMPENSATIONINSURANCE;` _._. ......
...__.
.- ._ -- - .-. . ._ .._.. ..__. ...
., IThii section need not be compleed if the Permit is for one hundred dollar
(Sim)or less.$ .
.;' i e nify,that in tn<p;Bawunce of Iti k fo which his permit is issued.I s., i •-
shall t ploy any ptirson in any ammuser so as to becomfeubject to the Workers'App]can
NCE A P T Ii�1t�1
al
me6me subj ct to the Worker's Compensenion provisions of the Liffmar Code you must
:0 fool th ply with such Provisions or this pc it shall be,J revoked,
oked,
r ._
`VI k•` " CONSTRUCTION LENDING AGENCY ' "l t rr
-, "I heart affirm that them is construction lending agency for the Performance r
-i-r nfah
L s Name
I.dor ._ - ..:_. T... ... .. -
_ z IsnJers Address
U,0 •I c edify Char l love read this application and sate that thin above informanam is
Lss-t: career 1 agree to comply with all city and counly.ordiwneex and state laws relaing
to building construction:and hereby amherim representatives of this city to enter upon
�.[]] the.1hi mentioned p,.,,,y for in.ppcdon purposes,
d a,,judlme tooave,Inde impippnd k hi hat a,in the way against
..d
Er-Z liabilities,j e'asoms,costs and expenses which may in any way accrue againd said
L,JrZ
APPLICANT
nsnsey NDERf the gDS AND this permit. 7
- `sr APPLICANT UNDERSTANDS AND LCOMPLY WITH ALL NON-POINT /L
sou EG IONS: •� " Issued by: Date
SrBnawrc ofPPIr .Dae Re-COOPS
, HAZARDOUS
F FIAZARDOUS MATERIALS DISCLOSURE
WIII the applicant or fumrt building e.Chapter
sore 2.and
he Health m maeriW Type of Roof -- -• - �- - '- - �--- -
C defined by the 32mp no Municipal Cole.Chap¢r 9.1?,ana the Health and Safety 7
G&la Oyes.,
yon2553'( 1 I ,' `: •' .t '. r .'
oY _..All.roofs.shall be inspected prior.to any-roofing-material being.installe(l._-.
w'.0 me appfpant nr mune nailams ne<apant nae egmpment nr aes;pea wnkh If a roof is installed without first obtaining an inspection;I agree'to`rerfiove
emit haz aims,air contaminants as defined by the Bay Arca Air Quality A1awscment ee
Distinct? I i all new materials for inspection. Applicant.understands and will comply with
ON. - all non-point source regulations. .... . . -
1 have read he baaadous'materiak requirenrend under Chapter 6.95 of the
C.Phyral6 Health&'Safety Col Sections 3505.25533 and 25534.1 understand that _
if Ne Wilding does not currently have a annual,that it is
mmsproohifty It)notity me
necupahl ohe qirents which ubereprior yis °ce ofa Certificate of
Occupancym
-
r _ Signature of Applicant _ Date
Al] roof coverings to be Class "B" of better
amhoriacd agnn Date OFFICE..