08050231 CITY OF CUPERTINO
BUILDING DIVISION "
PERMIT ' CONTRAG4TORPW ORMAT�IOfV-w
P,
PERMrr NO.
BulLpZlriG�grY'kEVENS CREEK BLVD STE TBD — TO BE DETERMINED 08050231
SANUARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
fop LICENSED COKIRACIOBS DECLARATION O O O O
�n 1 heroby.rtirn wt I atm nmsamd ander proviven ar Chepmr 9 anmmenmg Job Description
. wlths«tiro]0(107ofDividon3ofwButimuaMRofessiovCude.aedmyliccrmseh T. I .—SELFSERV YOGURT SHOP(TUFFI FRUTTI) , MODIFY
in full forte and circa
Llcmucclass Lm.g ELECTRICAL,MECHANICAL, & PLUMBING.
&g, Da¢ Cuntrutar ,
ARCHrfECTS DECLARATION
4 U 1 undemmnd my plans shall be used u public recards
1.0
,t', Licensed Profensiutnl
OWNER-BUILDER DECLARATION
.� Y 1 hereby affirm Nal 1 am exempt from Ne Conuxctors License Law for the
00 following roaann.(Section 7031.7.Business aM Profusions Code:My city or county
a 0! which mquims a permit In Con ries.alter.improve,dcmol W,ar repair any swetum
prior m es w Permit its issuance,Man requires applicant forsuch peit to file a signedstsmmmc
_Z� Net he is licensed pursuant tow provision of w Contractors l.icenm law(Chapmr9 Sq.Ft. Floor Area Valuation
�$ (Commercial,with Section,7000).(Divine.3.fffic Businessmal Prolessi..Code)Car $100000
e5— Nu he is exempt Nuefrom and the buss for the alleged exemption.Any violation of
Swum 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of �py�,
ant mem man BIM,Worked dollars ISM 32627035 .A&Number Occupancy P Y T YPe
❑I.uwmerofthepmpety,amycmplayeuwimwgnumebaolecampenudon,
will do wwoak,end w ammum 0 muimmmed suffered Russia(Sec.7014,Business
and Profesdan Code The Communes Lic.Law does not appy m m owner of Required Inspections
property who Wilds aimgovesmvme.md wandoessuch workhimself m Wough his
own employees,provided mat such improvements tie not intended uroRered for We.IL
however,the Wilding or improvement hisold within one yw of completion.w owner-
wilder will have Use burden of proving wt he did rot ddW or improve for Purpose of
sale.).
C I.u owner of the,property am exclusively contracting with liceued conmcmn to
construct the project(Sec.7044.Business and Profession Code)Tfae CoouxtMs U. .
cense law does not appy un an owner of property who Wilde or improves wmon,and,
who Co. "s far such jemwith eontrxeso(s)licensed pummm to w Consumes
rte
.B k PJt(m Nis mum
zr
Dem
WORKER'S COMPENSATION DECI,AMTION
I ha Y affirm under Penury of Kdary,oro of the following dmlasatlom:
Ihave and will mainuinaCcam ofConsentmul(-snort farwmkers Compere
sation,as provided fa by Section 3100 of the Iabm Code,for w partor .of the
work for which Nis permit is issued.
1 have and will maintain Wmkcra Compensation Insuran¢,as,required by Section
3740 ofw labor Code,far w performance ofw work f«which this permit is Issued.
My Workers Compensation Insurance carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPITON FROM WORKERS'
COMPENSATION INSURANCE
(ITh seedon need an,W cmmplemd lithe permit is foram hundred and us(SI00)
or leu)
1 unify Nat in the performance of w work la which this Permit is its .I Nall not
mnploYanypermn inany mxam,so�p9omesubjmtto W puuauen
Lawler Ce fomite Dam �a ✓✓fir t d ''1)
Applicant
NOTICE T'0 APPLICANT:If.after maqg this Certificate of Exemption.you mould
become subjett to the Workers Cumpeasaden ponnowa s of w Labor Code.you muss
Q O forthwith comply with such provisions or this permit Nall W decreed revoked.
z _.
gn CONSTRUCTION LENDING AGENCY
1 bcmby of irre wt Vert Is.concoction lending.,my for w performance of
lYi.moi
the work for which this permit is issued(Sco.3099,Civ.C.)
Q IanMrs Name
a lenders Address
U Q I certify that I have mad suis application W mute Nu the above inforramon is
lL ,^ correct.I agree m comply with all city and county mohnanen and tram laws mladng in
.Q rV^ Wilding consmaction,and hereby metwee representatives of mh city to enter upon de
Gil move-mentioned pmKnY for impaction purposes
„
11 (ural agree m ore,indeamily and keep harmless w City of Cupertino against
h Iimilhics,judgments.com andespeuns w ' may in my way accom againt said City _
U Z in conxgm ace,ofthe grantin h.
ti APPLI
Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willthe applicant or future Wilding nexpert nom mbandle momicus mmartad
0ned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
dc.Section 35532(4)7
❑Y'es ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cult honrwus it contaminants as dcfraed by the Bay Arca At,Quality Management all new materials for inspection.
Dismal P
❑Yes ❑No
I have mW mehr1mis amriab requirements under Chapter 6.95ofdue Caifm-
nhHWth SafmyC dE ccda LSS(15.25533 the ZT5M.luMxuand mu dding
ifw bu
0a,t ow ar(KL n_ Signature'of Applicant Date
rmmilu ri.<dmgo Dam All roof coverings to be Class'R!'or better