07110165 CITY OF CUPERTINO ° � ' �
Y3UILDING"DIVISION PERNIIT ����������������� `
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BUIL IN A RESS: PERMIT NO.
�0��� STEVENS CREEK BLVD BLDG R K ELECTRIC INC 07110165 .
OW 'S NAME: PERMIT LSSUE DATE
STARBUCKS 42021 OSGOOD RD ' 11/29/2007
/NE: SAMTARY NO. CONTROL NO.
(510)770-5660
ARCHITECT/ENGiNEER: BUfLDING PERMIT INFO
BI.DG ELEC[ PLUMH MECH
� � � �
u O p LICENSED CON7RACfOR'S DECLARATION JOU DCSCTlpt10(1
� I hcrcby sflirm that I am licenxd undcr provisions of Chaptcr 9(commcncing
�z� wiihSccdon7000)o(Division3ofiheBusinessand otcssions myliccnseis INSTL �UPLEX OUTLET
"� y in full force and eftect �•�
�j � Licensc au � Lic. N
n 1- Da1c . Contraclor V
� ARCHITECTS DECLARA N
e I undcrsunJ my plans shall bc uscd as public rccorda
, yU
4 O y Liccnsed RuCcssianai � �
n y � OWNER-BUfLDER DECLARATION
1 hercby alTirm ihat I am excmpt frum �hc Con�ractor's Liccnsc Law for thc
� p O following icasan. (SccUon 7031.5, Business and Profcssions Ca1c: Any city or rnunty
K$ Pi which rcquires a pemiit w conswc�, altcr, impmvc, demolish, or ie�wir any swcturc
y Z y prior w i�s iasuancc, also rcquires �hc applicant for such permit to file a signcd statcmcn�
_< that hc is liccnscd pucsuanl to Ihc pmvisions oC thc Conuactor s Liccnsc Law (Chapicr 9 Sq. Ft. Floor Area �, , 5 Valuation
y I- $(commencing wiih Secuon 7000) of Division 3 of ihc Business and Profcssions Cadc) or
y �... Nat he ia eumpt Nemfrom �nd Ne besia [or the alleged exempuon. Any violaeon of
Section 7031.3 by ury applicant for a peimit subjecu the applicam w a civil penalty of 3 5 9 0 8 0 2 2� Number Oceupaney Type
not mme than five hundied dollars (SS00�
❑[, u owner o[ tlie proputy, a my emptoyces with wages u their solc compensaUon,
will do Uie work. �nd ihe suuctwe is not intended or of[eeed for sale (Sec. 7044. Business Re uired Ins ections
and Profusiona Code: The Contexwr's License Law does not apply to an owner af q P
property who builda or improves thercon, and who does such work himself or Uuough his
own emplayces, provided that such improvemrn�s aro not in�ended or otfered (or sale. I[,
hawever, the building or improvement ia sold wi�hin one yar of compleuon, d�e ownu-
builder will have the burden of p�nving that he did no� build or improvc for pmpose of
sak.).
❑ I, u owner of We property, sm ezclusively conuacting wi�h littnaed rnnvutors w
construa the project (Sec. 7044. Businesa and Professions Cade:) 7tie Conuactor's Li-
cense Law does no� apply �o an owner of propeny who builds or impmves �Aeceon, and ,
who contracts for such pmjects with a wnvactar(s) licensed pursuan[ to the Contrxwrs
License Law.
❑ 1 am exempt under Sec. , B& P C for this rcason
Owner Date
WORKER'S COMPENSATION DECLARATION
I heroby �rm under penalty of perjury one of the foilawing declaradons:
,J 1 hsve and will mainuin a Cenificate otConsent to ulf-imure for Workcrs Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance o[ thc
work [or which Ihis pertnit is issucd.
❑ I have and will maintain Worlccr's Compauation Insurancc, as rcquired by Scction
3700 0( Ihe Labor Codc. fw thc pcdormance of Ihe work for which this permii is issued.
My Worke�s Compensatian 1 surance carricr and Policy number aie: Y
Cartier. Q ` Q- Poliey No.: �� ���
EKfIFICA7E OF EXEMPI70N FROM WORKERS'
COMPENSATIONINSURANCE '
(I'his settion need not be comple�ed if t6e permit is for onc hundred dollars (S 100)
or Icss) '
1 cenify Wat in thc perlormancc of ihc work fw which �his pertnit is issued, 1 shatl not
employ any pecson in any manncr so u to becomc subjcct to the Workers' Compensadon
Laws of Califomia. Ds�e
Applicam
NOTICE TO APPLICANT: lf, af�cr making ihis Ccnitica�c of Excmption, you should
become subjcc[ to thc Workcr's Compensation provisions of ihc LaAor Codc, you must
� O forthwilh comply with such pmvisions or this permit shall be dccmcd n.woked.
z ""' CONSTRUGTION LENDING AGENCY
E r ►�-� t hc�c6y afGrm Ihat thcre is a conswction knding agcncy Cor Ihc perfortnancc u!
�� Ihc work for which lhis permit is issued (Scc. 3097, Civ. C.)
W� Q Lendc�s Namc '
� z Lenders Addtcss
V � I certi[y �hal l have read this application and s�alc ihu ihe abovc inlormauun is
� ►" cortca I ag�ce w comply wi�h vl eity and county oreiinances and sw�e laws celating to
0 E'" building consuuction, and he�eby autharin representativcs of �his city w cntcr upon ihe
� a aAove-mcntioncd propeny tor inspcnion purpcues
(Wc) ageee to save, indcmnify and kecp hartnlest the City of Cupertino agtinst
H � IiabiliUa, judgmcn�a, costs and expenscs which may in any way acrnc against said City
V"Z in consequencc aC the granting af this permi4 Date ��' `�
�"� APPLICANT U ANDS AND WILL COMPLY WITH ALL NON-PO1NT Issued by:
SOURCE REGU ONS.
� � �� � Re-roofs ✓��
Signuuro o[ ApplicanUConuacwr Datc
HAZARDOUS MATERIALS D[SCLOSURE Type of F.00f
wll Ihc appiicant or futwc building accupant storc or handlc ha•rardous matcrial
as defincd by the Cuperlino Municipal Code. Chap�cr 9.t2, and the Healih and Safcty
c«� Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑ Ycs �o
�11 thc applicant or futurc building accupant usc cquipmcnt or Jcvices which
If a roof is installed without first obtaining an inspection, I agree to remove
eit ha•rardous air contaminants as dcfincd by thc Bay Arca Air Qualiry Managcmen� all new n aterials for inspection.
as�;���
pYes u
1 havc rcad ihe ha�ardnus matcrials requircmcn�s undcr Clup�cr 6.95 of thc Califoo-
nia Hcalih & Safcty Codc, Scctions 25505, 25533 and 25534.1 undcrsund that if Uic building
docs no� cumentl havc a tcnan�, ihai it is my maponsibiliry w nodfy thc accupant nf �he
rcyu�remcn�s h muu x met prior to issuancc o[a Ccni � a, o�occu Signature of Applicant Date
__� . �� fi All roof coverings to be Class "B" or better
Owncr or au�hore.cd agcnt ���
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