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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