B-2016-1256 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1256
20488 STEVENS CREEK BLVD CUPERTINO,CA 95014(369 53 999) ALL FOOD SERVICE
INSULATIO
1966 TICE VALLEY'
BLVD STE 142
OWNER'S NAME: MAURICE CHIN DATE ISSUED:03/08/2016
OWNER'S PHONE:.650-753-9168 . PHONE NO:408-316-8683
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class 5 Lic.#928389
Contractor ALL FOOD SERVICE INSULATIO Date 03/08/2016 X BLDG —ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH_RESIDENTIAL X COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
HAPPY LEMON(STE 2040)-T.I.TO REMOVE(E)YOGURT
I hereby affirm under penalty of perjury one of the following two declarations: MACHINES&REPLACE WITH FIXED SEATING.RELOCATE(E)
i. I have and will maintain a certificate of consent to self-insure for Worker's LIGHTING&ADD PARTITION WALL(400 S.F.)
f 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. Sq.Ft Floor Area: Valuation:$10000.00
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 APN Number: Occupancy Type:
ordinances and state laws relating to building construction,and hereby 369-43-9911-r A(Tenant Improvements),B(Tenant Improvements),B
authorize representatives of this city to enter upon the above mentioned h3 7s (Tenant Improvements),A(Tenant Improvements),A
property for inspection purposes. (We)agree to save indemnify and keep tJ L�✓ (Tenant Improvements),A(Tenant Improvements),A
harmless the City of Cupertino against liabilities,judgments,costs,and (Tenant Improvements),A(Tenant Improvements),A
expenses which may accrue against said City in consequence of the (Tenant Improvements),A(Tenant Improvements),A
granting of this permit. Additionally,the applicant understands and will (Tenant Improvements),A(Tenant Improvements)
comply with all non-point source regulations per the Cupertino Municipal
Code,Section 9.18.
f PERMIT EXPIRES IF WORK IS NOT STARTED
r Signature Date 03/08/2016 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
OWNER- LDERDECLARATION
X
I hereby affirm that I am exempt from the Contractor's License Law for one of the Issued by:ABBY AYENDE
following two reasons: Date:03/08/2016 U* CWC+�
1. 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 RE-ROOFS:
for sale(Sec.7044,Business&Professions Code) All roofs shall be inspected prior to any roofing material being installed.If a roof is
z. I,as owner of the property,am exclusively contracting with licensed installed without first obtaining an inspection,I agree to remove all new materials for
contractors to construct the project(Sec.7044,Business&Professions Code). inspection.
I hereby affirm under penalty of perjury one of the following three declarations:
i. I have and will maintain a Certificate of Consent to self-insure for Worker's Signature of Applicant:
Compensation,as provided for by Section 3700 of the Labor Code,for the Date:03/08/2016
performance of the work for which this permit is issued.,
2. I have and will maintain Worker's Compensation Insurance,as provided for ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
by Section 3700 of the Labor Code,for the performance of the work for which
.this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
3. I certify that in the performance of the work for which this permit is issued,I I have read the hazardous materials requirements under Chapter 6.95 of the
shall not employ any person in any manner so as to become subject to the California Health&Safety,Code,Sections 25505,25533,and 25534. I will
Worker's Compensation laws of California. If,after making this certificate of maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
exemption,I become subject to the Worker's Compensation provisions of the Health&Safety Code,Section 25532(a)should I store or handle hazardous
Labor Code,I must forthwith comply with such provisions or this permit shall material. Additionally,should I use equipment or devices which emit hazardous
be deemed revoked. 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
APPLICANT CERTIFICATION the Health&Safety Code,Sectipns 25505,25533,and 25534.
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 /f
relating to building construction,and hereby authorize representatives of this city Owner or authorized agent:
to enter upon the above mentioned property for inspection purposes. (We)agree Date:03/08/2016
to save indemnify and keep harmless the City of Cupertino against liabilities, rONSTRiu�1ION LENDING AGENCY
judgments,costs,and expenses which may accrue against said City in I hereby affirm that there is a;construction lending agency for the performance
consequence of the granting of this permit. Additionally,the applicant of work's for which this permit is issued(Sec.3097,Civ C.)
understands and will comply with all non-point source regulations per the Lender's Name
Cupertino Municipal Code,Section 9.18.
Lender's Address
Signature Date 03/08/2016 ARCHITECT'S DECLARATION