07010040 CITY OF CUPERTINO
BUILDING DIVISION PERMIT c� r� TaR ZR �IJN•
BUILDING ADDRESS:
PERMIT NO.
22601 VOSS AVE I TY O"
OWNER'S NAME: PERMIT ISSUE DATE
CITY OF CUPERTINO 22601 JOSS AVE 01/08/2007
ZONE: SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0 0
o p LICENSED CONTRACTOR'S DECLARATION Job Description
e V 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
=ZW with Section 7000)afDivision3ofthcBusiness and Professions Code,and mylicense is INTERI)R REMODEL-SNACK SHACK-CITY JOB
? H in full force and effect
? License Class Lic.#
t..,O Date Contractor
ARCHiTECPS DECLARATION
4
U 1 understand my plans shall be used as public records
G y Licensed Professional
y
OWNER-BUILDER DECLARATION
+�<2 1 hereby affirm that 1 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
e ff which requires a permit to construct,alter,improve,demolish,or repair any structure
y prior to its issuance.also requires the applicant for such permit to fife a signed statement
=o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
y H$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1500
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofA,A.1�MI G O 0 0 0„V bTumber Occupancy Type
not more than five hundred dollars($500). Cl V
❑I•is owner of the property or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q P
property who builds or improves thereon,and who does such work himself or through his
own employers,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.Business and Professions Code:)The Contractor's Li-
cense 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 Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
OwnerLADate
WORKER'S COMPENSATION DECRATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's 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 Worker's 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 carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certifv 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 Workcrs'Compensation
Laws of California.Date-
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z" CONSTRUCTION LENDING AGENCY
F~t�• I hereby affirm that there is a concoction lending agency for the performance of
(� > the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Leadcr s Name
Z Lcndees Address
V 0 1 certify that 1 have read this application and state that the above information is
w� correct I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We)agree io save,indemnify and keep harmless the City of Cupertino against
„Ht rA liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Cal
Date
SOURCE REGULATIONS.
Signature of ApplicanVContractor Date Re-roof;
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building 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)?
Q Ya ❑No All roof 3 shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Q No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,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
requirements which must be met prior to issuance of a Certificate of Occupancy. S Ignatui a of Applicant Date
Owner or authorized agent Date All roof coverings to be Class"B"or better