07010062 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
Cd�1�TRATO ItF ? M�4TIf�N•
PERMIT NO.
BUILDING ADDRESS:
1655 S DE ANZA BLVD # 7 TBD — TC BE DETERMINED 07010062
PERMIT ISSUE DATE
OWNER'S NAME: ,
7
SANITARY NO. CONTROL NO.
JE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
p a LICENSED CONTRACTOR'S DECLARATION Job Description
U
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is TI RE S TP URANT' REMODEL MINOR STRUCTURAL, K I KU
a a in full force and effect.
License Class Lle•p SUSHI
t-p Date Contractor
ARCHITECTS DECLARATION
7 < 1 understand my plans shall be used as public records
)aU
'u.F Licensed Professional
y
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
a a following reason.(Section 7031.5,Business and Professions Code:Any city or county
�m which requires a permit to construct,alter,improve,demolish,or repair any structure
u Z y prior w its issuance,also requires the applicant for such permit to rile a signed statement Valuation
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area 5 O O 0
i t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
L 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 �1 Number Occupancy Type
not more than five hundred dollars(5500). 36610061
❑I,as 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 docs Ilett 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 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
0ri.).
1,as owner of the property,am exclusively contracting with licensed contractors to
stmct 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 contractors)licensed pursuant to the Contractor's
License Law.
❑I exemp � .B&P C for is on -
Owner
Date
O 3
7 KER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑I have and will maintain a Certificate of Consent to self-insure for Workces 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 Workers Compensation Insurance carrier and Policy number are:
Carrier: Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc hundred dollars($100)
or less.)
I certify that in the performance the work for which this permit is issued,1 shall not
employ any person in any to the WorJce�Crnlpa}saLion
Laws of California.Date TT 35 dd77�0..LL
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
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z' CONSTRUCTION LENDING AGENCY
Fr►�- 1 hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
az Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
v. correct.1 agree to comply with all city and county ordinances and state laws relating to
rJ U building construction,and hereby authorise representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
C1. (We)agree to save,indemnify and keep harmless the City 0(Cupertino against
to liabilities,judgments,toss accrue and expenses which may in any way accragainst said City
U Z in consequence of the granting of this permit. Date
�+ APPLIC NT UNDERSTANDS AN WILL COMPLY WITH ALL NON-POINT Issued by:
SOURC EGULATI
Re-roofs
S' n pph t/Contractor Da Type of Roof
MATERIALS DISCLOSURE
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)) _ All roofs Ehall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant or future building occupant use equipment or devices which
If a roof iE installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes V1.
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
docs not cure ly have a tenant,that it is my responsibility to notify the occupant of the
rcquircmcw %Sqce4occrUrcateofoccwansy. Signature AApplicant Date
zz 5 6 All roof coverings to be Class"B"or better
Owner or adhorized agent 1521C