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CITY OF CUPERTINO
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BUILDING DIVISION PE1<
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BUILDING ADDRESS:
TARN'S CONSTRUCTION
PERMIT NO.
04050063
OWNER'S NAME:
PERMPI'ISSUE DATE
JAMES
PHONE:
SANITARY O. C RNOL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed -under provisions of Chapter 9 (commencing
p
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect '
License Classuc.p
TI— -ALEXANDER'S RESTAURANT
Date ContractorNO
SIGNS APPROVED AS PART OF THIS
ARCkI'PECiS DECLARATION
1 understand my plans shall be used as public records
PERMIT—PER GARY C.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractoes License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, 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 of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(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
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 ($500).
❑ 1, as owner of the propcny, or my employees with wages as their sole compensation,
0 0 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 orimproves thereon, and who does such work himself or through his
own employees, provided that 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 the burden of proving that he did not build or improve for purpose of
sale.).
❑ I. as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec. . B & P C for this reason
-7
0RK7 DECLARATI,O�
1
1 hereby affirm under, pen y of perjury one of the following declarations:
r
❑ I have and will mainlzii s 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.
❑ 1 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 Workees Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred dollars ($100)
or Icss)
1 certify that in the performance of the work for which this Permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Dare
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
i
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
i Lenders Name
Lenders Address
I I certify that I have read this application and stare that the above information is
' correcL I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorim representatives of this city to enter upon the—�
ahove-mentioned property for inspection purposes
(Wc) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, toss and expenses which may in any way accrue against said Cly
in consequence of the granting of this permit
-
APPLICANT UNDERST AND/ COMPLY WITH ALL NON -POINT
Issued by: Dat C�
SOURCE REGULATI P/
Re -roofs
Type of Roof
Z�-Z
Si Lure of A titan og ctor Dare
HRDOUS MATERIALS DISCLOSURE
Will the applic r future building occupant store or handle hayardous material
as defined by the Cupe no Muny� 'pal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)? �/
All roofs shall be inspected to any roofing material being installed.
❑Yes ®,No
prior
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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
. ❑ Yes (No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sceti 505. S a�y�U�35534. I understand that if the building
docs not currently have a a that rr r pdsponsibilily to notify the occupant of the
which � per ' cc of Certificate of Occupancy.
Signature of Applicant Date
rurecns
All roof coverings to be Class "B" or better
0,o,rmrauthoriycaage Date