11060072CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19060 STEVENS CREEK BLVD I CONTRACTOR: SMI CONSTRUCTION INC I PERMIT NO: 11060072
OWNER'S NAME: UNITED POLARIS INC
H'ER'S PHONE: 4082553999
LICENSED CONTRACTOR'S DECLARATION
License Class_ 6 Lic. # ,3 11
Contractor :E3 A4 L Date /T
1 hereby affirm that 1 am licensed under the provisions Chap er 9
(commencing with Section 7000) of Division 3 of the Bt iness & Professions
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of die work for which this
permit is issued
APPLICANT CERTIFICATION
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 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 t y of Cupertino against liabilities, judgments,
costs, and expenses which ma accrue against said City in consequence of the
granting of this permit. Add tonally e applicant understands and will comply
with all non -point source r la i s p the Cupertino Municipal Code Section
9.18
Signature Date_
•eby affirm that 1 am exempt from the Contractor's License Law for one of
tuc following two reasons:
1, as owner of the property.. or illy employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self - insure for Worker's
Compensation. as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
I 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 to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, 1 must
f<Mlnvith connply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
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 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 of Cupertino against liabilities, judgments,
co ", and expenses which may accrue against said City in consequence of the
Ig of this permit. Additionally, the applicant understands and will comply
1111 11011-Point source regulaticns Per the Cupertino Municipal Code, Sectiai
Signature Date
595 MONTAGUE AVE f DATE ISSUED: 08/15/2011
SAN LEANDRO, CA 94577 1 PHONE NO: (510)351 -3288
BUILDING PERMIT INFO: BLDG r— ELECT F- PLUMB F
MECH F- RESIDENTIAL r— COMMERCIAL F
JOB DESCRIPTION: MICHELLE'S PANCAKE HOUSE - COMMERCIAL. TENANT
IMPROVEMENT(]950SQFT }RESTAURANT SPACE INCLUDES
TYPE I HOOD, RESTROOM, SERVICE CENTER, KITCHEN,
Sq. Ft Floor Area: Valuation: $120000
APN Number: 37507046.19060 Occupancy Type.
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by_, — "JZ- ----�_ Date:
RE- ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If 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 "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) sho Id I store or handle hazardous material.
Additionally, should 1 use equi ent or devices which emit hazardous air
contaminants as defined by t Bay Area Air Quality Management District 1 will
maintain compliance with t Cupertino Municipal Code, Chapter 9.12 and the
Ilealth & Safety Code Sec o 5, 25533, and 25534.
Owner or author' a nt:
ate:
i
-/ C ONSTRUCTION LENDIN AGENCI'
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Profession