12110104CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19062 STEVENS CREEK BLVD CONTRACTOR: SMI CONSTRUCTION PERMIT NO: 12110104
INC
I OWNER'S NAME: UNITED POLARIS LLC/OLIVIA JANG 1595 MONTAGUE AVE I DATE ISSUED: 02/06/2013 I
OWNER'S PHONE: 4089058798 I SAN LEANDRO, CA 94577 I PHONE NO: (510)351-3288
EJ LICENSED CONTRACTOR'S DECLARATION
License Class_ Lic. # l
Contractorr"T Date 2 /ess
I herebyaffirm that I am licensed under the provisio s oapter 9
(commencing with Section 7000) of Division 3 of the Bus& Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, 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 provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
I certify that 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 relating
to building construction, and hereby aut rize representatives of this city to enter
upon the above mentioned property foe.inspection purposes. (We) agree to save
indemnify and keep harmless the pertino against liabilities, judgments,
costs; and expenses which may a rue agai t said City in consequence of the
granting of this permit. Additi the applicant nderstands and will comply
with all non -point source reg tions p the Cupe ino Municipal Code, Section
9.18. /
Date �?,/ 4C / /
❑ OWNF4-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, 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 & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, 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 provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
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 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 against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
JOB DESCRIPTION: RESIDENTIAL u COMMERCIAL
LITTLE SHEEP MONGOLIAN HOT POT- TO CLEAR CODE
ENFORCEMENT CASE- OPEN UP ROOM FOR
ADDITIONAL
DINNING SEATS, INSTALL TYPE 11 HOODS, INSTALL
Sq. Ft Floor Area: I Valuation: $8000
APN Number: 37507046.19062 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 80 DAYS OF PERMIT ISSUANCE OR
180 DAY F OM LAST CALLED INSPECTION.
Issued by: Date. S
RE -ROOFS:
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 "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505 25533, and 25534. I will
maintain compliance with the Cupertino M
uni I al Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) shI store or handle hazardous
material. Additionally, should I use equipt or devices which emit hazardous
air contaminants as defined by the Bay ea Air ual ty Management District I
will maintain compliance with the Cu tino M icip I Code, Chapter 9.12 and
the Health &Safety Code, Sectio 05,25 533, a� 3 .
Owner or authorized
I hereby affirm that there is a construction lending agency for the performance of
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
Signature Date