09010066CITY OF CUPERTINO
BUILDING PERMIT
J'
DIVISION
r
BUILDING ADDRESS:
PERMIT NO.
10123 N WOLFE RD FC-10
TBD - TO BE DETERMINED
ngninolsir)
OWNER'S NAME:
Jj�PERTINQ
PERMIT ISSUE DATE
SQUARE;
,,ON
A CONTROL NO.
ARCHTIECTlENGINEF.R:
BU)LDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions or Chapter 9 (commencing
with Section 700D) of Division 3 of the Business and Professions Code, and my license is
infull force and effect.
CHIARAMONTES PIZZA #FC10-T. I BUILD OUT ,OF FOOD CT
Dateense class contactor
INCLUDING KITCHEN.
ARCHrrECrs DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contactors Lice = Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct slier, improve, demolish, or repair any structure
prior to its issuance also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions or the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) or Division 3 of the Business and Proressiom Code) or
0 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SS00}
316 2 0 0 9 7 . F C -10
❑ L as owner or the property, or my employees with wages as their sole compensation,
Required Inspections
9 P
will do the work. and the structure is not intended or offered for sale (s«.70". Business
and Professions Code_ The Contractor's License Law does not apply to an owner of
property who builds or Improves thereon, and who does such work him -if or through his
own employees, provided that such improvements are not Intenuded or offered for sale If,
however, the building or improvement is sold within one year of compledoo, the owner -
builder will have the burden of proving that he did not build or improve for purpose or
sale.).
JR(I. as owner of the property, am exclusively contracting with licensed contractors to
'coAsu= the project (Sec. 7044. Business and Profcsslons Code:) The Cixivactoes LI-
eanse Law does not apply to an owner of property who builds or improves thereon, and.
who contacts for such projects with a contractors) licensed pursuant to the Contractor's
I L -_ Law.
❑ 1 am exempt under Sec B & P C for lids Mason
n
Owner f�iDae ��SL(
WORKER'S COMPENSATION DECVARATION
I hereby affhra under penalty of perjury one of the following declarations
❑ 1 hive and will maintain a Certificate of Consent to self -insure for Workces Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which Nis permit is issued
❑ 1 have and will maintain Wakces 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 Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CEXMCATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S 100)
or less)
I certify that in the performance of the work for which this permit is issued. I shall not
—ploy any person in any manner so as o b2 m bject to the Workers' Compensation
Laws or Calif Dale
Applicant
NOnCE TO APPLICANT: If. il)cr making this Certificate of Exp ption, you should
become subJcct to the Worker's Compensation provisions or the Labor Code, you must
forthwith comply with such provisions or this poxrnkt shall be deemed revoked.
I
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perform&= of
the work for which Otis permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lander's Address
I certify that 1 have read this application and sun that the above information Is
correct I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize 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 again%
j liabilities. Judgments, costs and expenses which may in any way accrue against said City
in consequmoc of the grandng of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
n
Issued by: Date
S U CE REG NS.
• -
Re -roofs
Type of Roof
signaure or Appliart/Conuactor Date
HAZARDOUS MA7ER ALS DISCLOSURE
Will the applicant or future building occupantstone or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.1Z and the Health and Safety
Code, Section2S532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or futwe building Occupant use equipment or devices which
—It hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
Dksuict7
❑Yes NO
I have read the hvm*m materials nequirwric is under Chapter6.95 of the Califor-
nia Health & SafayCodc, Sections 25505.25533 and 25534.1 understand tha if tic building
does not currently have a tenant that it is my responsibility to notify the occupant Of the
NVxnLswhie ustbemet 'orypi or a Certificate ofO=puwy.
Signature of Applicant Date
2
A] 1 roof coverings to be Class " " or better
Owner or authorized agent Date