06080204CITY OF CUPERTINO
77
BUILDING DIVISION PER*
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BUILDING ADDRESS:
PERMIT No06080204
:
SANITARY NO. CONTROL NO,
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG EL.ECr PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 701)) of Division 3 of the Business and Professions Code, and my license is
in full farce and effect.
T I A.LEXANDER' S RESTAURANT
License Class Lit. N
Date Contractor
.
FEES FOR REACTIVATION OF ## 0 4 0 5 0 0 6 3.
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for Uro
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to fie a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
VaNt" 0 6 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the buts for the alleged exemption. Any violation of
APN Number
Occupancy T
p y Type
Section 703 1.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500)_
31620052.00
❑ 1, as owner of the property, or my employees with wages as their solo compensation,
Required Inspections
will do the work and the structure is not intended or offered for sale (Sec.7044. Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale-).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Busines and Professions Code:) The Contractors Li-
censc Law does not apply to an owner of property who builds or improves thereon, and .
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
'
My Worker's Compensation Insurance carries and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
-
(This section need not be completed If the permit Is for one hundred dollars (EI00)
or less.)
I cenity that in the performance of the work for which this permit is issued. I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authoritt rcprescmatives of this city to enter upon the
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Signature of ApplicanUac Contrtor Dare
HAZARDOUS MATERIALS DISCLOSURE
AIM the applicant or future buUding occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected to any roofing material being installed.
❑ Yes ❑ No
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
omit hazardous air contaminants as dcftncd by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes ❑ No
I have read the hazardous materials requirements under Chapter6.95 of the Califor.
nia Health & SafctyCode, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant that it is my responsibility to notify the occupant of the
requi remcnis which must be met prior to issuance of a Certificate of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner
or authorized agent Date