080901770
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19620 STEVENS CREEK BLVD # 180
OWNER'S NAME: VERDE TEA ASSOCIATES
OWNER'S PHONE: 4089738899
0 LICENSED CONTRACTOR'S DECLARATION
License Class i? Lic. # 7 (S:-5 I' 5.
Contractor Zs/,giN PAttLDate ~ -f (-~?
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation, 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 provided for by
CONTRACTOR:GREATWALLBLDG
CONTRACTOR INC
PERMIT NO: 08090177
1689 VISTAGRAND DR DATE ISSUED: 02117/2009
SAN LEANDRO, CA 94577 PHONE NO: (510) 589-7528
BUILDING PERMIT INFO:
r
BLDG r ELECT r PLUMBr
MECH RESIDENTIAL r COMMERCIAL r
JOB DESCRlPTlON:COMM'L TI REST rNSTL RSTRM NON-STRC PRTN
WLS CL I
HOOD EQUPMNT SNKS& EQUPMNT-VERDE TEA
ASSOCIATES.VERDE TEA HAS BOTH SUITE #170&180.
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Sq. Ft Floor Area: Valuation: $80000
APPLICANT CERTIFICATION
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
APN Number: 36906010.170/180 Occupancy Type:
to building construction, and hereby authorize 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, judgments,
costs, and expenses which may accrue against said City in consequence of the
grantmg of this pennit AddItionally, the applicant under>tands and will comply
;ilt~ all non-po~t ::~r~~Cupertino Municipal Code, Section
S'gn,rure " -~ o.,,~1
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractor> to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations:
J have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this pennit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any marmer so as to become subject to the Worker's
Compensation laws ofCalifomia. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
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 building construction, and hereby authorize 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, judgments,
costs, and expenses which may accrue .against said City in consequence of the
granting of this pennit. Additionally, the applicant under>tands and will comply
with all non-point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
ISSuedbY~ Date: r~/Iff("
RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without fir>t obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERJNGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code-, Section 25532(a) should I store or handle hazardous ~aterial.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:
Date: 2-rr-~fX",,lM( ~/V" ~
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this pennit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
BUILDING DIVISION
BUILDING ADDRESS:
19620 T"'\lL"~IL'
OWNER'S NAME:
PHO SA CONTROL NO.
ARCHTffiCTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PWMB MECH
19. ~G 1-----L:-::
PERMIT
PERMIT NO.
COMM' L TI REST INSTL RSTRM CJ CJ CJ c::J
IC=EN:-::S=E=D"=C""O!'lffiA=-:-:cro=""'R':::-S""'DEC==-LAR-;-;;-:Ii.=:n=O:-::N-----+--"N:..:O:..:N:.=-:....S-=T::.R-=Cc..::...P-'R:..:.=T:.:N::..:..W--=L~S;.;;<..C=L'-J--';n.c=..::D"""e-"'sc'"'r-I·-p-'-ti-on--"'="-----'===---.l=:=-----==:!....
/ ~ 1 bereby aflirm thai I am lia:nscd under provisions of CbaplCr 9 (commencing U1Uu: ~!:!oJ with Section 7(X')(» ofOiyi5ion 3 of the Businc.ssand Professions Code. and my license is ....... ,... ...... --. _.......... -............. _ .. _ ...........
~ ::> in in full fan:c and cffect. ) el License CI ... L1c. # _~
~ t: ~ Dale ARCHm~;~~:-:::R-:cATI=O:-::N;-------
~~ -< I undc:nLand my plans shall be uscd u public n:cords
)leu
t u.!;; Licensed Professional :~j OWNER·BUILDER DECLARATION
I hereby allirm thai I am e.cmpt from iIle Canlractor's License Law for the~?< ~ .CO rallawing reason. (Section 7031.5. Business and Professions Code: Any cily or caunly Lall: which requires I permit 10 conslrUct" alter, improve. dcmoJillih. or rcpuir any structure ~~ VI prior 1O ilS issuance, also requires the applicanl for such pc:nnillo tile a signed stalCmcnt r--------;:;--;:;:-;:::;---.---~----T----------;-;-;_-;_---------: ~?< Lbal be is licensed pursuantla the provisions of the CanlraCLOr'S License Law (Cbapler 9 Sq. Ft. Floor Area Valuation ~XC ~r-£ (commencing with Section 7(00) 01 Division 3 nf the Business nnd Professions ~e) or
e~-that he i.1 exempt therefrom and the bub for the alleged exemption. Any violation of 1---------;-;;:;:7~-__;_---------+-------""""':;:::_----_,=--------
Section 7031.5 by any applicanl lor a permit subjccts the applicant 10 a civil penally of
not more than Ii"" bundred dollars (S500).
o I, as owner oflbe propcny, or my employees with wages as their sale compensation, L-
will do the warle. and the SUl!cturc is nal intended or alTered lor sale (Sec. 7044, Busin... I
and Professions Code: The Canlnl:LOr's License Law docs nal apply 10 an owner of
propeny who builds or improves !.hereon, and who docs such work. himself or throug.h his
own employees, provided thai sucb improvements arc nal inlCtlded Or alTered for sale. If,
however, !.he building or improvement is sold within one year of completion, me owner·
builder will bave lbe burden of proving thaI he did nal build or improve for pUlJlase of
sale.).
rI'J. as owner of the property. am exclusively contracting with licensed contractors ID
conslnlCl the project (Sec. 7044, Business and PrafcssiOM Code:) The ConlraCLOr's U·
cense Law does not apply to an owner of property who builds or improves lbereon. and .
who conlIaclS for such projects with a. con (s) licensed pursuanllO me Contractor's
License Law. o I am exemp, under Scc.;....~ T-==~=--,B '" PC for this reason
Owner ---r:===-=::::z~S=::ATI=ON=D-;:cEC;;;LA--;-;;RA~~N?{alo,
o I' nd will main lain a Certificate of Cansen, 10 self-insun: lor Worker's Campen.
sation, as provided for by Section 3700 of the Labor Code, for the performana: of the
work for wbieb this pennil is issued.
o I bave and will maintain Worker's Campensalian Insurance, as required by Section
3700 01 the Labor Code, for the performance of the work for wbich this permil is issued.
My Workers Compensation Insurance carrier and Policy number arc:
Carrier:__-=====-====Policy Na.:=====-_
CERTIFlCA1E OF EXEMmON FROM WORKERS'
COMPENSATION INSURANCE
(This section nced nal he compleled ilLbe pennills lorane bundred dollars (SIOO)
or 1=)
I ccnify thet in the perfannancc of the work for whicb this penni! is issued. I shall nal
employ any person in any man r ~ subjeclla the Workers' Compensation
Laws of California. Dale --"'"-I7..,.,."7'<>::",,L-----------
Applicanl __~--....",,...<:::......_,~jl'ii';il_....,::....---------
NOTICE TO APPUC
become subject lO W 5 C pc:nsBlion provisions of lhe: Labor Code. you must
forthwith co such provisions or this pc~iL s.haJl be deemed reVOked.
CONSTRUCTION LENDING AGENCY
I hereby affirm lhal there is .. construction lending aeency for the performance of
the work. for wbieb lbb permil is issued (Sec. 3097, Civ. C.)
Lender's Name ~-------------_
Lender's Address _
I certify thal I have read this application and stale lhal the above: information is
comet I agree to comply wilh all city and counly ordinances and slate laws relaLing to
building consuuetion, and bereby lulhori7.e representatives of Lhis city to cnler IJpon Lhc
ahoyC~mCnlioncd property for inspection purposes.
(We) agree 10 save, indemnify and keep bannless the Cily of Cupertino _gainsl
liabiliLies:.judgmcnlS. costs and expenses which may in any w~y accrue: against said City
in consequence: of lhe granting of this penni
APPLlCAJoIT UNDERSTANDS ILL
SOURCE REGULATION
clor
ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupan' Slare or bandle bazardaus malCriaJ
as dclined by the Cupertino Municipal Code. ChaplCr 9.12. and the Health and Safcly
Code, Section 25532(a)1
DYes ¥No
Will Lbe applicanl or fuu,", building occupant usc equipment or dcvices wbicb
emit hv.ardnw air conlaminanlS as defined by the Bay Area Air Qualjty Manac:mcnl
Distriel1
DYes ~Na
APN Number Occupancy Type
---:=-_-:_-:-:--__---: ~ _
• d
ReqUire Inspections
Issued by: Date
Re-roofs
Type of Roof
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.
Signature of Applicant Date
All roof coverings to be Class ''It'' or better