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ELI } LL
CITY OF CUPERTINO �T�TT
BUILDING DIVISION PE�r11T
BUILDING ADDRESS: PERMIT NO.
21979 SAN FERNANDO AVE YB CONSTRUCTIO
OWNER'S NAME: FEaMIT ISSUE DATE
CTTV OF (21112EIRMTNQ III AP 2009
PHONE: S A CONTROL NO.
'V'A D T R
(408) 316-1261
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u o o'Z LICENSED CONTRACTOR'S DECLARATION Job Description
Z5I hereby affirm that I am licensed under provisions of Chapter 9(commencing
tJ with Section 7000)o(Division 3 of the Business and Professions Code.and my license is
?Z<y in full force andcffect. BLACKBERRY FARM — TEMP PERMIT FOR CONCESSION
' License Class Lic.N
t in Date Contractor STAND
'U ARCHrrFCrS DECLARATION
�Fdd 1 understand my plans shall be used as public records AREA ONLY ELECTRIC, MECH& PLUMBING; ORIG PERMIT
goy LicensedPmfcssional #09020071 — NO INSPECTIONS AFTR 6/26/09
n y S OWNER-BUILDER DECLARATION
e 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
i p OeE following reason.(Section 7031.5,Business and Professions Code:Any city or county
.� to which requires a permit to construct,alter,improve,demolish,or repair any structure
prior tut its issuance,also requires the applicant for such permit to file a signed statement
_zQ
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
Yf (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of $100
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). 35710005 . 00
❑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 forsale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who doessuch work himself or through his
own employees,provided that such improvements are not intended or offered for sale 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
sake.).
ErT as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's U.
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 Contractor's
License Law.
❑1 am exempt under Sec ,B&P C for this reason
Owner c k I• Data 7
WoAkER'SFCOMPENSIMON DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compcn-
sation,as provided for by Section 3700 of the Labor Code•for the performance of the
work for which this permit is issued.
❑1 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 Worker's Compensation Insurance carrier and Policy number are:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
nr less)
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 became subject to the Workers Compensation
Laws of California.Date
Applicant "
NOTICE TO APPLICANT.If,after ffAking this Certificate of demption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.J Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z OCONSTRUCTION LENDING AGENCY
.t
1 hereby affirm that there is a construction lending agency for the performance of
pC > the work for which this permit is issued(Sec.3097,Civ.C.)
Q Lender's Name
] Lender's Address
U I certify that 1 have read this application and state that the above information is
LL cortecL 1 agree to comply with all city and county ordinances and state laws relating to
Q Fbuilding construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
LL (We)agree to save,indemnify and keep harmless the City of Cupertino against
tito liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit
�^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. 2�05
O Re-roofs
Signature of A canUContractor I Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes %futuNobuilding
Will the applicant or occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑Nu
1 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 tenant,that it is my responsibility to notify the occupant of the
rcyuiremWhich bcme riotlui�uanccofaCcnificaer�aZpan�. ,� Signature of Applicant Date
�/"I (T to All roof coverings to be Class'¢`'or better
Owner or authorize agent Date'
. (09
o�sPIS6
CITY OF CUPERTINO
TEMPORARY PERMIT
CUPEkTINO PERMIT APPLICATION FORM
APN # `( Date: /I
3S �-- L-' — �, u Sl2b a
Original Permit#
0 4?02 00-7
Building Address: e-
C, CA 4i
Owner's Name: Phone #:
� ,vtt b lem, -L(,o .6oZ6
Contractor: / Cis - Phone #: �Lg - 3(L r I Z6
J Fax #:
Contact: L� Phone #:
Contractor License #: cj SCS 4e7
Cupertino Business License #:
Job Description:
Valuation (cost of project): v Type of Construction:
Project Size: Over the Counter '��'
Quantity Fee ID Fee Description Fee Group Permit Type
1TEMPPMT Temporary Permit Good B 1TEMPPMT
J (Flat Fee) for 30 days —Commercial —
` only.
1BCBSC Cal Bldg Standards B ALL PERMIT
Commission Fee TYPES
01/07/09