09070129CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19068 STEVENS CREEK BLVD
O' Z'S NAME:
] LICENSED CONTRACTOR'S DECL ARATION
.icense Class 46 Lic. # � > 16, 6
contractor ��If T OF ate Date Wpt
I hereby affirm that I am licensed under the provisio o
commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
1 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
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
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 fo spection purposes. (We) agree to save
indemnify and keep harmless the , 0r, upertino against liabilities, judgments,
costs, and expenses which may crue against said City in consequence of the
granting of this permit. Addio6nally, the applicant understands and will comply
with all non -point source re lation er [he Cupertino Municipal Code, Section
9.18.
S; V Date—W-1-so 7
❑ OWNER- BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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
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 manner so as to become subject to the Worker's
Compensation laws of California. 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 d county ordinances and state laws relating
to' '''ling construction, and hereby thorize representatives of this city to enter
U above mentioned prope for inspection purposes. (We) agree to save
ins . wify and keep harmless th ity of Cupertino against liabilities, judgments,
costs, and expenses which may cc a inst said City in consequence of the
granting of this perm�Wtdit* nall th applicant understands and will comply
with all non -point soe lations r the Cu no Municipal Code, Section
9.18. / /
Date Qr !, V
CONTRACTOR: SMI CONSTRUCTION INC PERMIT NO: 09070129
95 MONTAGUE AVE DATE ISSUED: 08/10/2009
SAN LEANDRO, CA 94577 PHONE NO: (510)351 -3288
BUILDING PERMIT INFO: BLDG ELECT f— PLUMB
MECH r— RESIDENTIAL r COMMERCIAL
JOB DESCRIPTION:COM'L TI, RESTAURANT SUSHI HANA; NEW
REST -ROOM &
NEW KITCHN SVCS- SANITARY IS SUNNYVALE'S.
3q. Ft Floor Area: Valuation: $110000
^'LPN Number: 37507046.02 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DA S FROM L CALLED INSPECTION.
led b Date:
RE- ROOFS:
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 "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
1 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 material.
Additionally, should I use eqoftent or devices which emit hazardous air
contaminants as defined by a Bay Area Air Quality Management District I will
maintain compliance wit the ertino Municipal Code, Chapter 9.12 and the
Health &Safety Code, c tion 505, 25533, and 25534.
Owner or t1A O q.
Date: O </
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional