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CITY OF CUPERTINO
BUILDING DIVISION PERMIT��l''
BUILDING ADDRESS:
CA RNIA PIZZA KITCHEN
PERMIT N°. 06050044
19621 STEVENS CREEK BLVD
PERMIT ISSUE DATE
OWNER'S NAME:
CALIFORNIA PIZZA KITCHEN
19621 STEVENS CREEK BLVD
10 26/2006
SANITARY NO. CONTROL NO.
3NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Scotian and of or�J7�tsion 3 of the Business and Protessia�odc, and my license is
in full force and cffectJ.0
NEW COMMERCIAL SPACE/RESTAURANT
License I a l-� L�•x
Date �L"- Contractor
C�,LIFORNIA PIZZA KITCHEN.
ARCHITEC "S DECLARATION ye �bN ST L'-
�. J
1 understand my plans shall be used as public records '
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish• or repair any structure
prior at its issuance, also requires the applicant for such permit to file a signed statement
9
Sq Ft. Floor Area
p
Val$Mb1@ 0 0 0
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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 of1
�1�rIY.00T
Occupancy Type
not more than five hundred dollars (5500).
3 vs2
0 I, 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 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 or
sa�J.
0 I, 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-
ccase 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 Contractor's
License Law.
0 I am exempt under See B & P C for this reason
Owner Dale
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 Compcn-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
0 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 Cor�pvpenation Ins r�a�nce carrier and Policy r) t✓� —
Carier: ST I R�% L r JAIlicy No.:
CERTIFICATE OF EXEMPTION FROM WOR Rs'
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
forthwith comply with such provisions or this permit shall be deemed revoked.
' CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a convection lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
~ Lender's Name
Lender's Address
I certify that 1 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
building construction, and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
We) agree to save, indemnify and keep harmless the City of Cupertino against
O liabiliti ,judgments, costs and scs which may in any way accrue against said City
in con ucnce of the granting f s permit.
APP NT UNDERSTA NO WILL COMPLY WITH ALL ON -PO
Issued by: Date a
So ItBGU] ATIONS. /D 2 fi G
Re -roofs
Type of Roof
Sig urc l'Applicant/Contractor I DAc
HAZARDOUS MA ALS 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 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
d/�?
Will the applicant r future building occupant use equipment or devices which
..nit hazardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District? t
0 Yesu
1 vc read the ha.7-douls�m'arerial ircmcnts under Chapter 6.95 of the Cali for-
niaHca"SafctyCodcSections 25505,255 and 25534. 1 understand that if the building
docs t c ntly have a tenant, that' is responibilit to notify the oecu t of
rcyui n w}�itch mgst be mel pri w m reat. araenpam
gignature of Applicant Date
el
All roof coverings to be Class "B" or better
Owner or authorized agent I rDa