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CITY OF CUPERTINO
BUILDING DIVISION PER11�lT�[
17U 17u3 y„
PERMIT NO.
BUILDING ADDRESS:
21267 STEVENS CREEK BLVD #313
TBD — TO BE DETERMINED 07120083
:
SANITARY NO. CONTROL NO.
ARCHrIEC IENGINEER:
BUILDING PERMrr INFO
HLIX'i ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business ale Prof«aio co e, and my license is
T . I .INTERIOR MODIFICATION TO (E) I C ECREAM STORE
a in full forand effect
Ue:�a Lie u�
(YOGURTOWN) COUNTRTPS, 2 LIGHTG & ELCTRCL
Dam Contractor
,NEW
ARCHrrECrSDECLARATION .
OUTLETS— - -
1 my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby alum that I am exempt from the Contractors 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 sWctum
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed to the of the Contractors Lianas Law (Chapter 9
Sq. Ft. Floor Area
Valuation
pursuant provisions
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$ 4 0 0 0 0
that he is exempt tbeefrom and the basis for the alleged exemption. Any violation of
Number
Occupancy Type
section 7031.5 by any app0cam for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SS00)-
3 2 6 2 7 0 3 5
❑ L as owner of the property, or my employees with wages as thew sole compeasation,
Required Inspections
will do the work. and the Structure is not intended or offered rorsale (Sec. Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or thtoegh his
own employees, provided that such impmvemeats arc 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.).
❑ L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (See, 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 contnctor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under see. , B & P C for this reason
Owner Date
WORKEP'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
1 have and will maintain a Certificate of Consent to self -Insure for Worker's Compet-
n. as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued-
0 I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the wok for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
('This section need not be completed if the permit Is for one hundred dollars (S 100)
Of less.)
I certifv that in the performance of c woes fo hich this permit is issued, 1 shall not
employ arty person
be deemed revoked.
li CONSTRUCTION LENDING AGENCY
i hereby affirm that there is a wastrtrction lending agency for the performance of
the work for which this permit is issued (Sec 3097, Civ. C)
-
Lender's Name
,
Lender's Address
i i certify that I have read this application and state 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 eater upon the
l
above -mentioned property for inspection purposes,
(We) agree to save, indemnify and keep harmer the City of Cupertino against
j liabilities, judgments. costs and expenses which may in any way accrue against said City
' in consequence of the granting of IP4 permit
APPLICANT UNDERSTAND AND WILL C P WITH ALL N N-P?INT
Issued by: Date (_
SOURCE REGULATIONS. //J
Re -roofs
Type Of Roof
Signature of Applicaor Date
HAZARDOUS M DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as Wined by the Cupertino Municipal Code. Chapter 9.12and the Health and Safety
,
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or futoc building occupant use equipment or devices which
croft hazardous air contaminants as defined by the Bay Aron. Air Quality Management
all new materials for inspection.
District?
❑ Yes No
i havesad the oat materials requirements under Chapter 6.95 of the Califor-
nia Hcallh & Safety Code Sectio 25505, 25533 and 25534. I understand tinat irde building
does not currently haw a that it
Applicant Date
\
All roof coverings to be Class "B" or better
Date
owner or authorirrd agc