07080151BUILDING DIVISION PERMIT
BUILDjTIMYSS: ANDLEY DR
OWNER'
PHONE:
ARCHI ECTIENGINEER:
. 00 O LICENSED CONTRACTOR'S DECLARATION
u G 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
iZ W with Section 7000) of Division 3 of the Business and Professions Code, and my license is
o. in full force and effect -
License Class Lie. p
t- o Date Contractor
l ARCHITECTS DECLARATION
a I understand my plans shall be used as public records
tyU
U. � Licensed Professional
0
t S OWNER -BUILDER DECLARATION
tN
l a � 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following mason. (Section 7031.5. Business and Professions Cale: Any city or county
Qi which requires a permit to construct, alter, 'improve, demolish, or repair any structure
r — w prior to its issuance, also requires the applicant for such permit to file a signed statement
? 4
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(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. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
1, as owner of the property, or my employees with wages as thew sole compensatlma,
will do the work. and the structure is not intended or offered for sale (Sec. 7044, Busia=
and Professions Code: The Contractors License Law does not apply to m0woo of
property who builds or improves thereon, and who does such work himselfof ftv gh his
awn employees, provided that such improvements are not intended or o6hU for sale_ If.
however, the building or improvement is sold within one year of cordpktion, the owner -
builder will have the burden of proving that be did not build or improve for purpose of
sale-).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
ccnse Law does not apply to owner of property who builds or improves thereon, and
who contracts for such pmje with a contractor(s) licensed pursuant to the Con ors
License Law.
1 am "
DECLARATION
I hereby affirm on r penalty of perjury one of the following Zs:
on
❑ 1 have and will maintai a Certificate of Consent to self-irtsum far W es Compen-
sation, as provided for by Lion 3700 of the Labor Code, for the performance of the
work for which this permit issued-
❑ I have and will maintai Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued -
My Workers Compensation Insurance carries and Policy number arc:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is formic hundred dollars ($I00)
or less.)
1 certify that in the performance of the rk for which this permit is issued. 1 shall not
employ any person in any in--- cr bey�mc subject to the Workeri Compensation
Laws of Califyrnja
Applicant
NOTICE TO APPLICA : If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
2 forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
(--� 1 hereby affirm that there is a construction lending agency for the performance of
Q> the work for which this permit is issued (Sec. 3097. Civ. C.)
LL7 ~n Lender's Nam.
G1, Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
(L F" correct. I agree to comply with ail city and county ordinances and state laws relating to
0 U building construction, and hereby aythonze representatives of this city to enter upon the
W about -mentioned property or mspcctkon purpose&
(Wc) agree to sa indemnity and keep harmless the City of Cupertino against
�y V) liabilities, judgments, cos and expenses which may in any way accrue against said City
( ) 2 in consequence of the g ing of this Permit-
-
Date
III DOUS MATERIALS DISCLOSUREt
Willthe applica t or, future building occupant store or handle hazardous material
as de0nod by the Cope ino Municipal Code. Chapter 9.12_ and the Health and Safety
Code, Section 25532(a).
0 Yes No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defned by the Bay Area Air Quality Management
District?
Yes Wo
1 have read the hazardous materials mquiremctns under Chapter 6.95 of the Califor-
nia Hca & Safcy Cale, tions 25505. 25533 and 25534.1 understand if the bedding
does n cu I have a pant, that it is my responsibility to notify a occu t of Itrc
yuircments of a Ccnifi�"o u
0 6 r,
wncr or authorized a nt fDatc
PERMIT NO.
TBD — TO BE DETERMINED 07080151
PERMIT LSSUE DATE
08/15/2007
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
REPLACEING GREASE LINE IN KITCHEN, HOT DELI,
SHENKEE BAKERY. REPLACING T—BAR CEILING IN HOT
DELI
Sq. Ft. Floor Area
.MIGO 0 0 0 0 V:F4�umber
Issued by:
Re -roofs
Type of Roof
$0
Required Inspections
Occupancy Type
Date
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 "B" or better