09010036CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
OWNER'S NAME:
ARCHTTECTIENGINEER:
u p o LICENSED CONTRACTOR'S DECLARATION
cwi 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
z r, with Section 7000) of Division 3 of the Business and Professions Code, and my license is _
M ,0.„ in full force and effect.
j �2 Z License Class Lie. #
F, q Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
�av
wo N Licensed Professional
r OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Cantractor's License Law for the
q o following reason. (Section 7031.5, Business and Professions Code: Any city or county
0! which requires a permit to construct, alter, improve, demolish, or repair any structure
u 14 prier to its issuance, also requires the applicant for such permit to file a signed statement
x O that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
F (commencing with Sccdon 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 of
not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sale compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License 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 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 wilt 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 does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a c tractor licensed pursuant to the Convactots
License Law. 9y ! i
❑Ise exempt —6,Sea B & P C ar IN reason
�1!! ��
Owner ` Date
I WORKER' C NSATIO DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self-insum for warkees compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and pi 1 malnu d arks Compensation Insurance, as required by Section
3700 of the Latbo ode, C r ance of the work for which is permKis issued.
My Worker asa 'o a carrier and Policy number
Cartier. Polity No.;
&RtMCATE EXEMPTIONFROM W ERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars ($100)
or less.)
I certify that in the perfo me f the worlr for v hI this permit is issued, I shall not
employ any person in any a n so come su to the Workers' Compensation
Laws of Cali rural. Dat
Applicant
NOTICE TO APPLICANT. (f, after making this Certificate of Exemption, you should
Obecome -subject to the Worker's Compensation provisions of the Labor Codc, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
{Y r7 the work for which this permit is issued (Sec. 3097, Civ. C.)
W A Lender's Name —
z Lendees Address
U Q I certify that I have read this application and state that the above information is
It. 1-1 correct. I agree to comply with all city and county ordinances and state laws relating to
0 U building construction, and hereby authorize representatives of this city to enter upon the
W
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
HrA liabilities, judgments, costs and expense} which may in any way accrue against said City
lJ in consequcncc of the grant" f Iii permit.
APPLIC4, 7Dj
RSTA S D WILL COMPLY WITH LL NPN -POJ
SOUR, P'T Ij / ((
Sig to of ApplicanU a tract' Date
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)?
❑Yes r ONO
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
District?
❑Yes QNe
11
Ih'Iveroadlhehazardous tori quirementsunder Chaprer6.95ofUheCalifor-
niaHeaith&S elyCode, cu 25 5, 533and25534.1undcrstandthatdithebuilding
docs��� QQQQQQof a rte�h ly avei tcnan th u h responsibility to nodf*the occu(((���rrrhhht of the
requijerginls v(h�ihst or lance of a Ccrtifica (ofpCcuangy, %
234-4
Job Description
T.I CANDY STORE—FCK1(F00D CT) (M,E,P)
NON—STRUCTURAL
NO SANITARY CONDITIONS/REQUIREMENTS.
Ft.
APN NumberI Occupancy Type
31620094.FCK1
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date /_
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
'td�.
_7f
Signa a of Applicant Dale
. All roof coverings to be Class 'A" or better
PERMIT NO.
PERMIT ISSUE DATE
A
CONTROL NO.
BUILDING PERMITINFO
BLDG
ELECT
PLUMB
0
0
Job Description
T.I CANDY STORE—FCK1(F00D CT) (M,E,P)
NON—STRUCTURAL
NO SANITARY CONDITIONS/REQUIREMENTS.
Ft.
APN NumberI Occupancy Type
31620094.FCK1
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date /_
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
'td�.
_7f
Signa a of Applicant Dale
. All roof coverings to be Class 'A" or better