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CITY OF CUPERTINO
BUILDING DIVISION PERNIIT
CTtAC� 0R I1CFtMTE�11
BUILDING ADDRESS:
PERMrr NO.
10123 N WOLF
TBD —
OWNER'S NAME:
PERMIT ISSUE DATE
SA CONTROL NO.
ARCHITECTIENGIQEER:
BUILDING PERMIT INFO
TI—HOFBRAUHAUS EXPRESS IN
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
FOOD CT W/EXT ELECT/MS�I�escription
I heathy affirm that I am licensed under Provisions of Chapter 9 (commencing
with Section 7000) of Division 3 or the Business and Professions Cade, and my license is
in full fora and effect
License Class Lic. N
.
Date Contractor
ARCHITECTS DECLARATION
I understand my plats shall be used as public records
Licensed Profrxsional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 70313, 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 file a signed statement
Ft. Floor Area
Valuatiofi
that he is licensed pursuant to the provisions of the Contractors License Law (Cbapter 9
Sq.
(commenting with Section 7000) of Division 3 of the B usiness and Professions Code) or
that he is cxrmpl therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy
P Y Type
Section 703M by arty applicant for a permit subjects the apptir:azrt to a civil penalty or
not more than five hundred dollars (3M
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code. The Comuscuirs Llaase 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 Much 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 no build or Improve for purpose of
sale.).
❑ L as of the property, am exclusively contracting with licensed conuactos to
w the project. (Sec 7044. Business and Professions Code) The Contractors U.
cafte law does not apply to an owner of property who builds or Improves thereon. and .
who contracts for such projects with a conuacior(s) licensed pursuant to the Contractors
LJar6e Law.
❑ 1 am
wReTIO
1 herby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compeo-
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 WwWs Compensation Insurance, as required by Section
3700 of the Labor Code• for the performance of the wolf for which this permit is issued
My Worker's Compensation Insurance carrier and Polity number am:
Carrier. Policy No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be compacted if the permit is for one hundred dollars ($100)
or less)
1 certify thou In the
you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby afire that there is a construction lending agency for the performance of
the work for which this permit is issued (Sce, 3097, C(v. C.)
Lender's Name
Lenders Address
1 certify that 1 have road 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 hemby authorim representatives 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, juogments, costs and experscs h may in any way accnre against said City
in
Date
HAZARDOUS MA s nlscl.osuaE
Will the applicant o tutors ng occupant score or handle hazardous material
as defined by the Ct no M pal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment o devices which
emit hazardous air contaminants fined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes No
-e
1 have read the hazardous materials requirements under Chapier&95 of the Califo-
Ir
nice Hcnith & Safety Code, SectionsW53,d.1 understand thaz if the building
�, (dos
not