07010064 CITE'OF CUPERTINO ., T �n
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
10235 S DE ANZA BLVD ANGEL' S PL
PERMIT ISSUE DATE
OWNER'S NAME:
MIKE/VARDY LLC 495A MADERA AVE 01/10/2007
SANITARY NO. CONTROL NO.
LONE: (408) 280-0907
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0 0
o p LICENSED CONTRACTOR'S DECLARATION Job Description
eu F 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing "PEBBLES DELI CAFE" ILLUMINATED SIGN, CHANNEL
=Z w with Section 1000)of DivisioQ of the Business and Professio Code,andym�y license is
y in full force and efffCL LETTERS
,1? License Class Lic.S
F o Date_—1n Contractor .
A CHi7ECT'S DEC Tl
I understand my plans shall be used as public records
rJa
O
y Licensed Professional
n y
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
is O O following reason.(Section 7031.5,Business and Professions Code:Any city or county
kms, 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 file a signed statementValuation
—?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $2900
(commencing with Section 7000)of Division 3 of the Business and Professions Code)of
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 of 35910060 APN Number Occupancy Type
not more than five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as thein 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
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 We.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 Contractors
License Law.
❑1 am exempt under Sec. B&P C for this mason
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
��Ave and will maintain a Certificate of Conscnt to self-insum for Workers Compen-
;9fion,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 Workers 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.)
1 certffv that in the performance of the work for which this permit is issued,I shall not
employ any person in any manncrso as to su
become bjecct�Workers'Compensation
Laws of California.Date
Applicant — `
NOTICE TO PLICANT:!f,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
Fr►r I hereby affirm that them is a construction lending agency for the performance of -
a+> the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
0 z Lender's Address
V 0 1 certify that I have read this application and state that the above information is
LL correct.1 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 properly for inspection purposes.
a (We)agree to save,indemnify and keep harmicss the City of Cupertino against
►F-t liabilities,judgments,toss and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date /�O
�-- APPLICANT UNDERSTANDS AND W LL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
Grp f D o Re-roof:
HAZARDOUS
nature of Applicant/Contractor DateType of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Muni'pal Code,Chapter 9.12,and the Health and Safety
Cede.Section 25532(a)? All roof;shall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant or forum building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants 'defined by the Bay Area Air Quality Management all new materials for inspection.
)istrict?
❑Yes ❑No
I have mad 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 respoibility to notify the occupant of the
requirements which must be met prior to i uance o7 erufteate of Occupancy. Signatul a of Applicant Date
10
nerorwtharizcdagcnt Dare All roof coverings to be Class"B"or better