04010053 CITY OF CUPERTINO ''t' 'M '
BUILDING DIVISION PERMIT CONTRACTOR INF
BUILDING ADDRESS: TESCO CONSTRUCTION PERMIT NO 04010053
#ERS NAME: ax -A 111111AIFoo ATE
NE: S N O. CONTROL NO.
ARCHITECT/ENGINEER: — BUILDING PERMIT INFO
ELECT PLUMB MECH
0 0 0 0
u00 LICENSED CONTRACTOR'S DECLARATION
u 1 hereby affirm that l am licensed under provisions of Chapter 9(commencing Job Description
with Section 7000)of Division 3 of the8ia ncsaanO Proresaiona Code.and my license is
^ � mmnf e of t. TI (STORE FRONT)
>�? Licence CC'a, r E Ac —
" — s ORIG. #03070019 EXPIRED/PAY 1/2 OF PERMIT FEES
qq ARCHITECTS LARATION
:,le U I undcrstanJ my plain¢hall he useJ as public rccoNs -
;oh Licensed Professional
S OWNER-BUILDER DECLARATION
MI I masa .(Orin thin 1 am exempt from the fessions o :Anyc Law for the
0 00 whichfollowing reason.(Section](131.5.Business and improve.
de Professions Cole:Any City nr county
K
which inquires d issuance.also re sires the
alter.lm Forsu,h permit t ore a sir anygned tatement
yZY
that
its ensedpalwnt in thuhovisio so for such Permit License
Law(Cha mem
Z< that(comme cccnaud Pursuant in the of Division
of the eBusinesind Professions
(Chapter Sq.Ft. Floor Area Vah]®tgO�10 00
zttO Mattie is exeming pt
hheefrn rand of basis for
of al lege BusinessandProfessions Cale)of 4
y 3� Nat he is uempt therefrom end the buil for Ne alleged exemption.Any violation of
Section 9031.5 by any applicant for a peamil subjects the applicant W acivil penally of anC APN Number Occupancy Type
not more than five hundred dollars ISSUE). P Y YP
❑I,as owner Of the property,or my employees with wages as their salt compensation, 31620037 . 00
will do the work,and the structure is not intended or offered for solo(Sec.1044,Business
and Professions Cade:The Contractor's License Law does not apply W an owner of Required Inspections
property who builds or improves thereon,and who does such work himseifor through his
own employees,provided Nat 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 Ne burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of On property.am exclusively contracting wit licensed contractors la _
construct the project(Sec.7044,Business and Professions Code:)The Co mmus's Li.
cease law does not apply to an owner of property who builds or improves thereon,and
who conimcts for such projects with a contrectons)licensed pursuant to the Contractor's
License law.
❑1 am exempt under Sec. .B&P C for this moon
ere Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of Perjury on of the following declarations:
I have and will maintain a CCNfcate of Cement to self-insure for Worker'sCounter.
antion,as provided for by Section 3700 of On Labor Code.far the peRormance of Ne
work for which this permit is issued.
-- ❑1 base and will maintain Workces Compensation Insurance,as required by Section
3100 of the labor Code,for On performance ofthe work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
ere. No.:
C s,
CERTIFICATE OFEXEf�ItON FROM WORKERS'60'"M� C/OM�PPEN$ATIIONN IN Ry♦NC6 SUY}
(This auction nex(',Beokmd Tlhe FcYmtiti"2121=hundreddo11mr—( 191)
nr less) m
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 an to become subject o the Workers Compensation
Laws of Cottfomia.Dam
Applicant _
NOTICE TO APPLICANT:IL after making this Cenifica a of Exemption,you should
become subject to the Worker's Compensation previsions of the labor Code,you must
.J 0 forthwith comply with such provisions or this Permit shall be deemed residual.
Z ti CONSTRUCTION LENDING AGENCY
Ihereby 3fErm Nat there is a Canstructinn lending agency for the Performance of
C' the work for which this Permit is issued(Sec 3(19],Ci,C.)
QLender's Name
.u7. z Lcrder'a Address
U 0 1 certify that 1 have read thio application and state that the above information is ,
124 P cortoct.I agree 19 comply with all city and county ordinances and scale laws relating to
OU building construction,and hereby auNortx rcpmscnndws Of his city 19 enter Upon the
W above-mentioned property for inspection purposes. '
0. (we)agree W save,indemnify and keep broadcast the City of Cupertino against /
Iiabilitiu-judgments,casts and expenses which may In anyway accrue against said City
UZ in consequence of the graining of this Fermis.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU REGUL S.
O - a Re-roofs
ignearn ofA r°°HAZARDOUS MATERIALS DISCLOSURE _Dam Type of Roof
Will Ore applieam or future building occupant pore or handle hamrdous material
as Outlined by the Coastline Municipal Code.Chapter 9.12,and the Health and Safety
e,Section 25532(a)? All roofs shall be inspected prior to an roofing material being❑Yea �Nu P P Y g g installed.
Will the applicant or future building«cupam use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cmil hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ANo
I have mad the haraNaus materials requirements under Chapter 6.95 of the CrEfor.
air Health&Safety Code,Sections 25505,25533 oral 25534.1 understand Nat if he Wilding
docs not Cuncmly haw a tenant,that it is my normal hility,W nodfy the excupant of Or
maim ntswhi us anorrirtoissuareamr.c.nif eupancy. Signature of Applicant Date
Y 0 All roof coverings to be Class"B" or better
Owner or antillihis,ol agent Dale