07040133CITY OF CUPS 11NO
BUILDING DIVISION
PERNUT
BuILDjNY0 STEVENS CREEK BLVD TBD - TO BE DETERMINED
OWNER'S NAME:
PHONE
ARCHITECT/ENG 1 MER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
rith Section 70(111) of Division 3 of the Business and Professions Code, and my license is
a full force and effect.
.icense Class Lic• N
)atc Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
.icensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
'ollowing reason. (Section 7031.5, Business and Professions Code: Any city or county
Phich requires a permit to construct, alter, improve, demolish, or repair any structure
irior to its issuance, also requires the applicant forsuch permit to file a signed statement
.hat Iii• is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
;commencing with Section 7000) of Division 3 of the Businessand Professions Code) or
That he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 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 for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law dors not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
howe4cr, 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
sale.).
U I, as owner of the property, am exclusively contracting with licensed contractors to
ebnstruct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
ccnse Law docs not apply to an owner of property who builds or improves themon, and
who contracts for such projects with a eomraetor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. , B & P C for this reason
Owner 1 � --1 Date I o f
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, 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 required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier.
Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
((itis section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so to become subject to the Workers' Compensation
Laws of California. Date —�- n '�
Applicant
NOTICE TO APPLYCAN : If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Codc. you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hemhy affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ, C.)
Lender's Namc
Lender's Address
I certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise representatives of this city to enter upon the
above-mentioned proTrrty for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabililies,judgments, costs and expenses which may in any way accrue againstsaid City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCEREG.VLAMONS.
b v
Signature of Applieanr/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstorc or handle hayArdous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
District?
❑YcsNu
1 have mad the ham ous materials mquimmencs under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505,25533 and 25534. I understand that if the building
docs not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which m si be met prior to issuance of a Ceniftcate of �c/�P�ancy.
n—,
PERMIT NO.
07040133
FERMfr ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
Job Description
REVISION—PASHA'S MARKET—KITCHEN HOOD @ FLOOR SINK
LOCATION. ALL MECHANICAL EQUIP ON ROOF MUST BE
SCREENED—FOOD TAKE OUT ONLY—NO SEATING INSIDE OR
Sq. Ft. Floor Area
37507046.qlNumber
Issued by:
Re -roofs
Type of Roof
$0
Required Inspections
Valuation
Occupancy
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class "B" or better