07050015 CITY OF CUPERTINO
BUILDING DIviSION PERMIT S GTt'�R INEbR 4TION« :'
PERMIT NO.
BUILD�NQQD��ESSN TANTAU AVE SOUTH BAY CONSTRUCTION CO 07050015
PERMrf ISSUE DATE
OWNER'S NAME:
SOUTHLAND FLAVOR CAFE 170 KNOWLES DR 05/21/2007
SANITARY NO. CONTROL NO.
INE:
(408) 373-5500
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
i p zo LICENSED CONTRACTOR'S DECLARATION Job DOSCTIptlOn
U[= I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z w with Section 7000)of Div ion 3 of the Business and Professions Code,and my license is NEW ELE TR I CAL ROOM & DOOR T. I .
r a a in full force and effect. "7J
j License CI s Lic.N
p Date Contractor 500,rm
a
ARCHITECTS DECLARATION
i a< 1 understand my plans shall be used as public records
)aU
v F Licensed Professional
a OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
3 n O following reason.(Section 7031.5,Business and Professions Code:Any city or county
<W which requires a permit to construct.alter,improve,demolish,or repair any structure
Z} prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
a that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 ;iq.Ft.Floor Area $27017
t=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
it 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 ofe p Number Occupancy Type
not more than five hundred dollars(SSW). 3 1 6 18 0 2 5:�7
❑1,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 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 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 docs 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.
❑1 am exempt under See. B&P C for this reason
Owner Date
WORKER'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 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 InsuranA,',
' nd Policy number are:
Carrier. ` vlicy No.:
CERTIFICATE OF ON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify 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
O forthwith comply with such provision or this permit shall be deemed revoked.
z 'R CONSTRUCTION LENDING AGENCY
rA I hereby affirm that there is a construction lending agency for the performance of
LY r7 the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
az Lender's Address
U C I certify that I have read 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
Ubuilding construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned properly for inspection purposes.
LL (We)agree to save,indemnify and keep harmless the City of Cupertino against
Hl] liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in cone c of the granting of this permit.
APP CA NDERSTANDS AKD WICOMPLY))/ITH ALL NON-POINT Issued by Date
S RCE REGULATIONS. fi//
'� Re-roofs
pplicant/Contractor F
are Type of Roof
HAZARDOUS 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 ihall be inspected prior to any roofing material being installed.
❑Yes <fuLu
If a roof i 3 installed without first obtaining an inspection,I agree to remove
Will the applicant orbuilding occupant use equipment or devices which
emit hazardous air contaminanis defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes o
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health 4rSarc%Ccdc,Section 25505,25533 and 25534.1 understand that if the building
does not/urmnqVhavc a tenant,that i MyleponSibiliLYLOnOtifYffiCOCCUPantOfLhC
rcquircents which must be metprix t issn nr a seri ate nIOccopan Signature of Applicant Date
2, All roof coverings to be Class "B"or better
Owner or authorized agent Date