03120014 CITY OF CUPERTINO .�' r�' a�. '�:n ' "�
BUILDING DIVISION PERMIT ftORA.CTUR�INFU NIATTUNs,.-'
BUILDING: PERMIT NOO 3 12 0 014
WC)T-FIR RG
R'S NAME: PERMIT ISSUE DATE -
ONE: SANITARY ONTR
. COOL NO.
ARCHITF.CTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Y00
LICENSED CONTRACfOR'SDECLARATION JobDescri tion
]he It affirm Nat 1 am Ilmnwd under pmvision of Chapmr 9(commauing P
withsccgon7pfal)of Divlslon3ofthe Bus* dProfessinn,Code,and mylimmois
mmnm naerrem G TENANT IMPROVEMENT
5 L full f CI s Li
D,m z IBREAKTIME DESSERTS & SNACKS
cant
ARCHITECTS RATION
deaundmyplans ahanmused aspublic records CONTRACTOR: SMI CONSTRUCTION (02/11/04)
iGIn Licensed Pnsraast...I
5 OWNER-BUILDER DECLARATION
f I hereby effirm Net I am exempt from the Contractor's License Law for the
i O O following mason.(section 7031.5,Business and Professions Crede:Any city or county
$ which requires a Permit tin construct,alter.improve,demolish.or repair any mm.mm
Fly
prior it)its issuance.also requires the applicant for such permit to rile a signed statement
xx<
dust k is licensed pursuant to the provisions of the Commetur's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
�dF$ (Commwin&with Section 700))of Division 3 of NC B.,lnessand Profeasinns Code)m
i�' ... Nat he b exempt durations and the bssb for the alleged exemption.Any vloladan of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of APN Number Occu ane
not mom man fin hundred dollars($500). P Y�YPe
❑I,as owner ofrhe property,or my employees with wages as their sole compensation,
will do the work and thestormuse snot intended mothered Russia(Sec.7044,Bonuses 31605052 . 00
and property
cede:The Cantremor.Licensendwho Law does;not apply lf an owner of Required Inspections
progeny who s,po oded thiwsch improvements
amdwhp aeesmehwoek himselrorNmugh his
nown ,
however,the building Ntl improvement
sin ne year fc oraffempletimd tarsale.r.
builder ,the building orimprovementissold withinone year ofcompletion,Neowner-
builder will have the burden of proving that k did not Wild or Improve for purpose of
talc.). f j
❑1,as owner of the properly,amusineexclusivelynd Pomading with:)The
conlrmmn -
0 1,as the project(Sec.704d,Business and Profsssti na Code:)The d comotm.LI- X
cense Law coca not apply in an with
a of progeny who Wilda or lm,to ft Nemon,and
whence Law.for such pmjecu with a camractor(s)Iimnutl puravam m Ne Conuectota
License Law. VY
ten exempt untler Sec .BdePCfor Nls mason
ei
Data
WORKER'S COMPENSATION DECLARATION
1 thereby+R3nn under penalty of perjury ow of Ne following declarations:
I hew and will meinuin a Certificate of Cement m telt-Imumfor Workers ComPen-
more.as provided for by Section 3700 of the labor Cods,for the performance of the
work for which this permit is issued.
❑I Mw and will maintain Worker's Compensation Insurance,as required by Section
37W of me Ube,Code,for Ne performance of the work for which Nis permit is Issued.
My We
ere Compensation Insurance artier and Policy n kr am:
a rLSTi4Tk �uND Policy No.: 6/?D �_D
CERTIFICATE OF EXEMPTION WORKERS'
COMPENSATION INSURANCE
This section need not kcompleted if tic permit is form=hunarcddollus($100)
nI ICSA)
1 mnify that in the Performance of One work for which this Permit u honed,l shell nut
employ any person in any manner an as to kcome subject to the Workers'Compensation
Law,of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this CeniOcam of Exemption,you mould
become subject to the Worker.Corporations previsions of Ns Labor Cnde,you must
.J,Z foMwith comply with such provision,or this permit shall Is,deemed revoked.
.Zi O
CONSTRUCTION LENDING AGENCY
I hereby alfng Nm Nem is a construction lending agency for the performer oI
a the work fur which this permit is issued(Sec.3097,Ci,C.)
W� Q Lender's Name
n1. z London's Address
U Q I modify that 1 haw read this application and state Net the akw information is
ICn F correct.I agree to comply with all city and county ordinances and slow laws relating to
Q V Wilding construction.and hereby authorise representatives of this city m enter upon me
U above-mentioned property for Ice n purposes.
es,j agree m mw,ind nify and kith harmless titc City or Cupertino against r/
it N figtiin
of
cusum ex macs which may in any way accrue against said City I/ (//
(„)7 in conuquencc ofN ti go rmiL
r� PPLICA T U T N DWI COMPLY WI NON-POINT Issued by;3 DatO
RCE REG 10
/ Re-roofs
Signator fApplicmU ontndor m
H ARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicmor futurebuildingCode.
Chanterore 9.12.handle Health
rdandmarmal
Suetye
Section
io Ne Cu nino Municipal Code.Chapter 9.11.and the HeaIN and Safety
Oben us3z(b7 Ya M17 Nu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I itt ftp Nous air contaminants so defined by the Bay Area Air Quality Management all new materials for inspection.
[I yes P(No
I have mad me haverqursmycSalarcquimmenu under Chapter
6.95 of Nc Glirm.
nia Hal"Satiety Code, &NgaSY5505,25533 mJ15534.1 understand that iftim Wilding
does not currently haw r LW at it my msponsi ty m nodl'y me occupant of Nc
mqu' menuw cmetp`n`yprN' testa of Occup eY. Signature of Applicant Date
� 1 i (/ D fG
mer or authorized 0gerl Bate All roof coverings to be Class"B"or better