07100139CITY OF CUPERTINO1.
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BUILDING DIVISION TERNM
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BUiL11iHJ(3,�I�D�tES$,,TEVENS CREEK BLVD
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KAS HOME IMPROVEMENT CO.
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07100139
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3140 W ANACAPA WAY
02/14/2008
PHONE
SANITARY NO. CONTROL NO.
(714) 992-6861
ARCHITECT/ENGiNEF.R.
BUILDING PERMIT a4m
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70M ofDivision 3 of the Business and Professions andmyliccneeis
TENANT IMPROVEMENT —NEW YOGURT SHOP, NON
in full force and effect
License Clan Lie. 8 A
STRUCTURAL
Date AR �sDECLARATION r
INCLUDES E/M/P
I understand y plans shall be used as public records
,
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Conuactees License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to concoct. alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
he is licensed to the of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that pursuant provisions
Section 7000) of Division 3 of the Business Professions Code)
$ 6 0 0 0 0
m (comencing with and or
that be is exempt therefrom and the basis for the alleged exemption. Any vlolation of
3 6 9 0 6 0 0 9 Ay,� Number
Occur ane
P Y Type
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
not in= thin five hundred dollars (scam.'
.
❑ 1, as owner of the property, or my employers with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
.
awn employees, provided that such improvements are not intended or offered for sal& If,
however, the building or improvement is sold within one year of completion, the owme-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
consthnct the project (Sec 7044. Business and Professions Code:) The Contraemrs I.S-
cense Law does not apply to an owner of property who builds or Improves thereon, and ,
who contracts for such projects with a contracmr(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec , B & P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby aQum under penalty of perjury one of the following dedwadons
❑ 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 Worker's
F�EXIMPTION FROPolicy **M WO�4LZ
COMPENSATION INSURANCE
(this 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. I shall no
employ any person in any manner so as to become subject to the WorkersCompensation
Laws of California Dale
AppBcam
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation previsions of the Labor Cock, you must
' forthwith comply with such provisions or this perntit shall be deemed revoked.
I
'
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued (Sec 3097, Civ. C)
L.endces None
Lenders Address
i I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws rebaring to
' building construction, and hereby authorise representatives of this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino agsina
j liabilities judgments costs and expenses which may in anyway accrue against said City
inconsequence of the granting ofthispermit.
APPLICANT UNDERSTANDSS ANDDWILL: COMPLY WITH A11. N -POINT
Issued by: Date
SOURCE REF
MATERIALS DISCLOSURE
Will the applicant or future building occupant pore a handle hazardous material
as defined by the Cupertino Mu 'dpal 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 No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emir hazardons sir contaminants defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes No
I have mad the hazardous; materials requimments under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building
of the
does not currently have
roof coverings to be Class "B" or better
g
. � �
once authorized etc