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CITY OF CUPERTINO
BUILDING DIVISION PEPJVHT
BUILDING ADDRESS:
PERMIT NO.
10123 N WOLFE RD FC9
TBD — TO BE DETERMINED
08090 07
OWNER'S NAME:
PERMIT ISSUE DATE
9 9 8
PHONE:
A O. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
.•
BLDG ELECT PLUMB MECH
0 0 a 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 700) of Division 3 of lho Business and Professions Code, and my license is
CHIARAMONTE' S DELI --- COMML TI SAUSG&DELI
in full force and affect.
License Class Lie."
Date Contractor
SHOP , ELEC r MECH&PLMi rB ADD PRTN WLS SOFFIT&T—BAR&1
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
TYPE#HOOD&STP DWN TRANSFRMER 5 9 3 SQ
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant far such permit to rile a signed statement
License Law 9
that he is licensed pursuant to the provisions of the Contractor's (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
5 3 3 7 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(S500).
3 1 6 2 0 0 9 4. FC 9
❑ I, as owner of the property, or my employees with wages as their sale compensation,
Required Inspections
q P
will do the work, and the structure isnot intended oroffered 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
awn 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 Thal he did not build or improve for purpose of
sale.).
as owner of the property, am exclusively contracting with licensed contractors to
c nswct the project (Sec. 7044, Business and Professions Code:) The Contractoes Li.
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Law.
❑ i am exempt on Sea , B & P C for this mason
OwneDate
�1�(RI S COMPENSATION RATION
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 Workees camper.
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:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becomplctcd if the permit is foronc hundred dollars ($I00)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so aXo bccpo subject to the Workers' Compensadon
Laws of Calif!mj- ate —
_
Applicant , _
NOTICE O A IVT: If, after making I� crtificatc or Exemption, you should
become subject to the Worker's CompensDtffin provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
r CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a construction lending agency for tine performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lendees Name
Lender's Address
j I certify that I have read this application and stale that the above information is
r correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and herehyt authorize representatives or this city to enter upon the
above-mentioned property for inspection purposes.
(Wc) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit,
7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
S RCCULATI S.
i y 4 Z-
Re -roofs
-Signature AfrpifiiartDCantractor Dare
of
HAZARDOUS MA RIALS DISCLOSURE
Type Of Roof
Will the applicant or future building occupantstore or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(x)7
All roofs shall be inspected prior to any roofing material being installed.
E] Yes JRNo
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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes 7Qa
1 have read the hazardous materials requirements undcrChapicr6.95 of the Califor.
nia Health & SafetyCodc, Sections Z5505,25533 and 25534.1 understand that if the building
dors not currently have a tenant, that it is my responsibility to notify the occupant or the
uiremc which t be met prior to issuance of a Certificate of Occupancy.
Signature of Applicant Date
-
All roof coverings to be Class "j, 'or better
0 ncr or aulho ze agent Date -