06020036 CITY OF CUPERTINOv �fatrx-»a+ = `"�'� ,
BUILDING DIVISION P)Ci RMITC01TRACTaR=INFOLMATC174N
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BUILDING ADDRESS: PERMIT NO.
22350 HOMESTEAD RD
NER'S NAME: PERMITL4UHDATE
PEETS COFFEE & TEA 03/24/2006
PHONE: SANITARY NO. CONTROL NO.
ARCHIIEC(ENGINEER: BUILDING PERMIT INFO
BO ELECT PLUMB
MECH
O
j O p LICENSED CONTRACTOR'S DECLARATION
U 1 hereby.ffiren that I am licensed under provision of Cbarmer 9(commencing Job Description
withSmtion70(gOef Divlaion3efdw Budin as Psofeeines Cod,andmse
ylicenh
4� immllfmceandelTact Lice TENANT IMPROVEMENT-NEW COMMERCIAL SPACE
Z
Li
eanAn circa .
Dam C.waster
ARCHITECTS DECLARATION NO SANITARY REQUIREMENTS 3/22/06 PER NICHOL
[understand my plana shall he used as public..us
g Licensed Professional
G
y OWNER-BUILDER DECLARATION
i 1 bcrehy aRmm that 1 em exempt from the Conoam es License Law for the
Oe) following mason.(Section 7031.5,Business and Profession.Calc:Any city or county
5$ which mquima•permit on eeriswet..Imr,hnprova.demolish.m repair any sanctum
_ZLm prior An its issuance.alto requires the applicant for such Permit to File a signedatammdnt
< that he is licensed puruant in de provision a she Commuter's Llmnse Law(Chman,9 Sq.Ft. Floor Area Val��ttT x�f[Lp�5
(commencing with Section 7000)of Division 3 of the Business and Profusions Code)or Y000
IRE3 that he is eaempl t herefrem and the bash for the Alleged exemption.My violation of
Section 7031.5 by Any applicant for a Permit objects the Applicant m.civil penalty of APN Number Occupancy Type
not marc dun 0w hundred dollars DSM.
❑1,as owner of the property,or my employe=with wegu u chair sole compensation,
will do the woh,and thdstructure Is not intended m offered forsald(Sec.70a.Business
and Profession&Code:The Convector's Liam Law dads cot apply m a owner of tttggga Ir Actions
propeuywhobaiprovid provided
Mercer.and who dmaeahended smselfedthrough his I���
property whoa,provided that such M Int r.and w to tae not intended oroRerW Torula is -
however,the building or Improvement is sold within one you of completion.the owner-
bulldu will have dw burden of proving Inn ba did not hdid or improve for purpose of
ale.). t' iia Q
0 ns
I,u owr of the Property,un cx.Wively contracting with Iiaum ed contra!&& JUN •y 2,006
construct the project(Sec.7064,Business and Professions Code:)The Contractor's LI-
moa law dons nm apply u an owner of property who Wilde or Improves thereon.and.
whomnoacu for such pmJems with acpnuutor(q licensed Pmawmadm Cpntrsours �® 8��'NG
.hemelact U
0 I am exempt under Sec. .B&P C for this mean
nu Dam
WORKERS COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury am of the following Oeciantions:
0 1 have and will maintain a CW0=te of Covent wself-Insure fsr .Worker'aCanpen-
adon,As provided for by Section 3700 of the labor Code,for the performance of the
wodr for which this permit is iemd.
0 1 have and will maintain Workers Compensation Insurance,As required by Section
3700 of de Labor Code,fro the performance oft the wart per which this permit Is issued.
My War rs Com madam I saran=crier and Policy number Ad
Grrier. f Policy No.: �f
K
CERTIFICAT• EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ThisseNm need not W completed ifthe permit is foronc hundred dollars($1001
or less)
I Mrtifv Nat In We performance of de work for which this Permit is issued,I&hall not
employ any person in my manmrso As An become subject to the Workeri Cnnpevation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cer ificew of Exemption,you should
become subject ut the Worker's Compensation provisions of the labor Code,you most
0z rorthwith comply with such provisions or this permit shall ba domed mwked.
EE O hardly
LENDING AGENCY
E0
Ihardly alarm tut dere its countertenors lending agency for Ne performance of
fYi
the wars for which this permit h issued(Sec.3097.Civ.C.)
W Lander.Name ,
z Landers Add. .
V Q I certify that 1 have ma4 this ppliculon end sum that Ne shove in(onn.tiun h
lL F
correct.I agree to comply with ail city and county oninuees and sum Ism relating m
0 U building construction,and hereby autheriae mpmsematives or Ni&city to enter upon the
W above-mentioned property for inspection purposes
(We).gree to aro,indemnify and keep harmless the City of Cupertino ag.iut
rrA Imbilitiu.Judgmenu.costs And expcuu which may in my way&cc=against aid City
in C)"" APPLICANTeof the UNDERSTANDS Aof IN�onILL COM ITH ALL NON-POINT Issued by: Date
SOURC ULATI O
O Re-roofs
of Appli=evCeniram Dam
HAZARDO MATERIALS DISCLOSURE Type of Roof
Will the.pplicam orf building acorat Bore orhandk huudous material
As deffm l by Ne Cuperino unicipd Coder Chapter 9.13.and the Health ad Safely
Suction
en 255324)?)7 All roofs shall be inspected prior to any roofing material being installed.
uc o
Will the applicant or future building occtp of use c4uipmeni or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Arch barsrdnus air contaminatsu dcOgctl
District? �
by Ne Bay Arca Air Quality Management all new materials'for inspection.
0Yue f3Nu
1 hoc and the intend.,mmcdalso quimnunm under Chaper6.95 ofthe Cslirm.
sitHulth&SefnyCede,Sadmv25505,25533 ad25534.1on dulifthd building
Jas not currently have a mnan4 that h h my Ihilily tify Iba pat of de
reyulremcn hkhmunhemi 'anises ars camof,§cccacy. Signature of Applicant Date
Ow prawhodadagem am All roof coverings to be Class"B"or better