04060147 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C01\?,TY2A.C'';TURN1+Uii1VIr�.�IUN ,
BUILDING ADDRESS; "'"""04060147
ERMIT"04060147
10919 N WOLFE RD
OWNER'S NAME: PERMIT ISSUE DATE
I .C. CREAMERY
E: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
00 LICENSED CONTRACTOR'S DECLARATION
Y V I hcrcby art,.that I am licensed under provisions of Chapter 9(commencing Job Description
< with Section 7000)of Division 3 of the Business said Prefescion Code,and my license,is
^ y in full force and effect. SIGN—
License Class Lk.#
Z Dak Contractor
3FARCHITECPS DECLARATION
1 undeo and my plans shall be used u public records
C U
3 Licerued Professional
OWNER-BUILDER DECLARATION
<� 1 hereby affirm that I am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
X$2 which requires a Permit to construct,altar,improv,demolish.or repair any structure
tore prior or its issuance,also requires the applicant for such permit o file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapkr 9 Sq.Ft. Floor Area Valuation
a (commencing with Section 7000)of Division 3 of dm Buaincu and Professions Code)or
that he is exempt Iheefrom and the basis for the alleged Gumption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofe10 0 Occupancy Type
not
.or...than five hundred doll.($500).
❑I,as owner of the properly,or my employees with wages as then sole compensation,
will do the work,and the structure is not intended or offered forsalm(Sec.7044,Business 114
and Professions Code:The Conwcrors License Law does not apply to an owner of Requir pections
property who builds orimposas themon,and whadoessueh workhimul(orthrough his /\
own employees.provided thattemb improvements are not intended oroffered for sale.If, /V� t
however,the building or improvement is old within one year of completion,the owner.
builder will have the burden of proving that he did not build or improv for purpose of / '-
cola.).
h as owner of the property,am exclusively contracting with licensed camraCton to
cause La the es not (Sec.o an owner
oas and Professions Cade:)The Convector's Li-
cense law docs not apply to an owner of propenY who Wilds or improves thereon.and.
who convacu for such projects with acontncri licensed pursuant to the Contactora
License Law.
❑l am exam under Sec .B R P CCffar
Lthis
/seoas�n
Owtkk/ Dam
o'-
WORKER'S COMPE ON DE@TIO
herby sRrm under Penalty of perjury one of tm following declarations:
h.Iave and will maintain a Conificek ofConum to self-insure far Worher
saaCompen-
donprovided far by Section 37W of the labor Code,for the performance of the
work for which this permit is issued.
❑I haw and will maintain Worker's Compensation Insurance,as inquired by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. -
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Obis section send not W completed!fine Permit is formic hundred dollars(SIM)
or Ices)
1 certify that in The performance of the work for which this Permit is iunod.I shalt not
employ any pcfson in any manner an as W become subject to the Warkcn'Compensation
Laws a(California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
became subject to the Workers Compensation previsions of the Labor Code,you must
.JO forthwith comply with such provision or this Permit shall W deemed revoked.
ZCONSTRUCTION LENDING AGENCY
[tego!)
r I hereby affirm that thea is a construction lending agency for Inc performance of
ai
the work(art which this permit is issued(Sec.3097,Civ.C.)
W Q Lenders Name
z Lender's Addreas
U Q I unify that 1 haw reed this application and sok that the above information is
G.F contact 1 agme to comply with all city and county ordinances and sure laws elating to
0 Wilding convection,and hemby autharie epreacntedws of this city to enter upno to
W shove- o.
(We)sicd properly for Inspe...loon keep W
(We)agme to cove,indemnify and hath hay in an the City of Cupertino s against
ferry liabilities.judgment,caao and expenses which may in any way acerae against said City I
V Z in consequence of N=granting of this permit
�••� APPLICANT UNDERSTAN AND WI OMPLY WITH�L OOPO_IyT Issued by: Da[
SOURCE GULATIONS. tt79J
Re-roofs
gra o Appl _HAZARDT ATERIALS DISCLOSURE iK Dam Type of Roof
Will the applicant or forum Wilding occupan4torc or handle havNoua materiel
as defined by the Cuperfino Municipal Code.Chapter 9.12.and the Health and Safety
Cade,Sccoon 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant ave Wumng ocmapan'ase equipment on deviates whish If a roof is installed without first obtaining an inspection,I agree to remove
I he,_
air contaminants as fined by the Bay Amu Air Quality Management all new materials for Inspection.
tric'?
❑Yea u
I have now the Menelaus mowns a requirements under Chapter 6.95 of the Cables,
.is Health A Sammy Code,Sectors 25505A5533 and 25534.1 understand todiftk Wilding
done ria ermemly haw a kraut,than' Ts my rtes sibili muily Ne,occupam of the
regain swhichmustbc t nor nin=amaf u = Signature of Applicant Date
Ow r out ohne =art Dam All roof coverings to be Class"B" or better