04040095 CITY OF CUPERTINO > `_7r -.;.
BUILDING DIVISION PERMITCONTRACTnR INFORMATION.
lk
BUILDING ADDRESS: PERMIT NOO 4 04 0 0 9 5
_10330 N WOLFE RD
:R'S NAME: PERMIT ISSUE DATE
JAMES CHEN 04 15 2004
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMETINFO
BLDG ELECT PLUMB MECH
uop LICENSED CONTRACTOR'S DECLARATION
��� 1 nereny arfirm mal I am Beenwa ander prnviamna nrcnnpter v¢nmmeneing - Job Description
wi th Section ndefof Divixion3of me Business and Professions Cndc.and mylidcnu is
in ens.Co, erreC1' DEMO-- (E) RESTAURANT
Limnse Class Lic.tl
Datc Chromic,
eeF ARCHITECTS DECLARATION
you I undersand my plans shall W used as public rcenNs ovp,
;0y Ucensed Pn,fcssional p,DO��
OWNER-BUILDER DECLARATION
E a 0 hereby maso affirm(Sird oro exempt from me Contractors : Law for the
iwO follwhich
guiresa (Section]fn Lr,Business and improve,
demob Code:Any city structure L,v which requires a permit re uires the
alter,improve,h Permit
erm tt or repair any ehucmre 12 0 0 0
hother to sscensece,alaurequire thovisiosofcant for sucContrator'torleaeLaw(m¢mcnt
ExC thmhcisliccnscJpursuamlothcpmvi nsnRhcContracmr'sLicense Law(Chapmr9 Sq.FLFloor AreValuation
(commencing with section]gf10)of Division 3ofthe Boniness and Professions Code)or
that be is exempt therefrom and the basis for had alleged exemption.Any violation of
Section]831.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than five hundred dollars(S5W). or Occupancy Type
D 1,as owner of the property,or my employees with wages as their sole compensation,
will do thc work,and the structure is not intended or offered for ole(See.7Ba4,Business
and Professions Code:The Cnntacmr's License Law does not apply to an owner of Required In tions
property who builds or improves thereon.and who dues such work hinge f or through his
Own employees,provided that such improvements are not intended or offered for sale.If,
however,me building or improvement is sold within on year of completion,the owneo-
builder will have the burden of proving that he did not Wild or improve for purpose of O
salt.).
1,as owner of the property,,B exclusively contracting with licensed contractors i \
comma the does
(Sec:o an Business and Professions ds or
The Contractors nd
ansa lntw docs dol apply a an owner of property who builds ar impto the Norton,end
who contracts for such projects with a contmnor(s)licensed pursuant to the Contractor's -
Licanse Law.
❑I sm exempt mother Sec. p ,B&P C for this mason
r m
F WORK 'S COMPENSATION DEC1'ION -
1 hereby of ind under penally of perjury one of the following declarations:
D I have and will maintal n a Certircam of Consent to self-imam for Wman'a ComKn.
nation,as provided for by Section 3700 of me labor Code,for the peormmance of the
work for which this permit is issued.
D I have and will maintain Worker's Compensation Insumnve,as required by Section
37W of the Labor Code.for the performance of me work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he Completed if the permit is for one hundred dollars($P00)
nr lcssJ
I cenify that in the pedommnce of the work for which this permit is issued,I shall not '
employ any person in any manner so a to become subject a the Workeri Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Ceni ficate of Exemption,you should
become subject to the Worker Compensation provisions of the labor Code.you ni
.J� forthwith comply with such provisions or this permit shall W deemed revoked.
zO CONSTRUCTION LENDING AGENCY
[--� I hereby affirm that there is a consuuclion lending agency lot the performance of
!Yi 7 the work for which this permit is issued(Sec.3(19],Civ.C.)
W Lender's Name '
z Lender's Address
V Q 1 ecnify mal 1 have read this application and state that the above information is
W carted 1 agree to comply with all city and county ordinances and state laws relating to
O(J Oildingconswaiomand hamby authorize repressmativcs of this city to enter upon the
above-mentioned pmpeny roe inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Vl
in
fthecostsantl ex penseswhich may in anyway accrue against said City
V z A APPLICANT
of UNDERSTANDS
of this permit.
a'^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date rJ
SOURCE REGULATION .
o Re-roofs
Shipemr of Ap,lica VCon actor ❑ p
HAZARDOUS MATERIALS DISCL S Type of Roof -
Willtheapplicantor future building occommismrc o andleharardousmamrml
as derided by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
e.Section 25532ta)?
E]yes ZNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or turn=building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harardom air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
Yes V1 No
1 have read the huxerduus`maicrials requirements under Chapter 6.95 of the Califon
ads Him lth&Safety Calc,Secdmer 25505,25533 and 25534.1 undersand that ifthe Wilding
does net currently haw a tenant,that it Is my responsibility on and I the a,capset of the
reonatrams which must he met poor is,issuance of a Ceniremc of acupancy. Signature Of Applicant Date
11//n/41/
pate All roof coverings to be Class "B" or better
Owner or au nri'rcd age