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CITY OF CUPERTINO
BUILDING DIVISION g►�,1s T1'
j.,,.. ol
BUILDING ADDRESS.
PERMrr NO.
10235 S DE ANZA BLVD
ANGEL'S PLASTIC
OWNER'S NAME:
PERMIT ISSUE DATE
495A MADERA AVE
01/10/2007
PHONE:
SAN TARY NO. CONTROL NO.
(408)280-0907
ARCHITECTIENGINEER:
BUILDING PERMrr1NFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
hereby
Job Description
affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70ew)ofDivisioQofthe Business and Professio Code, andmylicenscis
"PEBBLES DELI CAFE" ILLUMINATED SIGN, CHANNEL
in full fora and cf[fct. �� 1.�.• t in '
License sass L.Ic. a
LETTERS
Date — _ Contractor
A CHI"I'ECTS DECLARATI
1 understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5. Business and Professions Cale: 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 forsuch permit to file asignedswement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
S Ft. Floor Area
q •
Valuation
$2900
commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Airy violation of
35910060 APN Number
Occupancy Type
Section 703I.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (5500)
❑ I, as owner of the property, or my employees 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 Contractor's License Law does not apply to an owner of
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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,
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 Contractor's 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 Contractor's
-
License Law.
❑ 1 am exempt under Sec , B & P C for Wiz reason
,
Owner Dale
WORKER'S COMPENSATION DECL ARATTON
1 hereby affirm under penalty of perjury one of the following declarations:
sve and will maintain a Certificate of Consent to self -insure for Worker's Compen-
on, 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 Worker's Compensation Insurance artier and Policy number are:
Cartier. 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 less)
f 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 the Workers' Compensation
Laws of California. Date — '" `'' S'
AppBant
NOTICE TO4PLICANT. If, after making this Ccrtifiate 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.
)
' CONSTRUCTION LENDING AGENCY
1
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.)
Lenders Name
,
Lenders Address
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
4
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 o(Cupertino against.
I liabilities,judgmcnis, costs and expenses which may in any way accrue against said City
of the granting of permll
A
APPLICPLIC ANTNT A UNDERSTANDS AND W LL COMPLY WITH ALL NON -POINT
Issued by:
of Roof
Ignaturc of ApplicanUContrector Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futum building occupant store or handle hazardous material
as defined by the Cupertino Muno ipal Code. Chapter 9.12, and the Health and Safety
Code, Section ass3z(a)7 ❑Yes N
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
cmlt hazardous air contaminates gs'defined by the Bay Area Air Quality Management
all new materials for inspection.
DLstrii:0
❑ Yes ❑ No
I have read the hazardous materials requirements under Chapter 6,95 of the Califor-
nia Health& Safety Code, Sections 25505,25533 and 25534. 1 understand that if the building
does not currently have a tenant, that it is my resPW bBity to notify the occupant or the
requirements which must be met prior to trance o a crtificatc of Occupancy.
77
�a� r f� v
Signature of Applicant Date
All roof coverings to be Class "B" or better
*ncrorauthorized agent Datc