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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO.
21979 SAN FERNANDO AVE
ROBERT A BOTHMAN INC
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
LET DaR
S CONTROL NO.
(408)2.79-2277
ARCHITECTIENGiNEER:
BUMMING PERMIT iNFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
I hereby affirm that I am licensed under provisions of Chapter (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license Is
in full force and effecL
T.I. CONCESSION STAND— (E) HOOD REPLCMNT, (E) GREASE
License
�nseclass Coruraaor
TRP RMVL, GREASE INTERCPTR & ASSOC . SANTRY CONNECTS
ARCHr1E(.TS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, after, improve, demolish, or repair any structure
'
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
10 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of
not more than five hundred dollars (S500).
35710005.00
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
win 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 side. 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.).
, as owner of the property. am exclusively contracting with licensed contactors to
construct the project (Sec 7044. Business and Professions Code:) The Contractors Li-
cense 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 Contractors
License Law.
❑ I am exempt under Sec , B & P C fo this reason
Own Hale 2—
�WOR
'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a certificate of Consent to self -insure for WorkeesCompen-
sadon, 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 Workers 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 artier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF F EMPIION FROM WORKERS
COMPENSATION INSURANCE
(This section need riot be completed if the permit Is for one hundred donan Wall
or less.)
I certifv that in the performance of the wort for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers Compensation
aws of California. D
Applicant
NOTICE TO APPLI : If after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I 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.)
Leaders Name
Lender's Address
I certify that I have read ids 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 in any way accrue against said City
inconsequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL NON -POINT
Issued by: Date v J v
SOUR REGULATIONS.
Re -roofs
Type of Roof
Signature of Applianl/Conuactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhandle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and We Health and Safety
Code, Section zss32(a)?
❑Yes
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
Wme applicant or future building pant oar
Will PP use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
No
❑ Yes
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
does not currently have a W=4 that it is my responsibility to notify the occupant of the
requirements which must be reel prior to issuance of a Certificate of Occupancy.Signature
of Applicant Date
A]1 roof coverings to be Class '%'' or better
Date '
Owner or authorized agent