09040098CONTROL NO.
408)942-8200
PERMIT
CITY OF CUPERTINO
BUILDING DIVISION
ARCHITECTIENG1NEER:
PHO
BUILDING ADDRESS:
OWNER'S NAME:
BUILDING PERMIT INFO
BLDG ELEcr PLUMB MECH-+
.. ~-Ibol he " exempt thererrom and Ibe bas" ror Ibe allCGed exemption. Any violation or I---;-;:=~;-___,;---------I----''''-='~~~~-----=_-------_
Section 7031-S by any appllcanl ror a permit subjects Ibe applican'lO' civil penally or APN Number Occupancy.Type
IKlI mon: Iban five hundrcd dolla.. ($.500).
31609037.APLo I. u owner of lite property. or my employees with wa~ as ll1cir sole compellSltiO.,~.Il1c~~~~~-~~~~or~~~~~7~~~~---------------~R~-~·-d~I~--~·------------~-----
and Professions Code: The ConuaelOr's License Law docs not apply 10 an owner or equlre nspectlons
propeny who builda or improves Il1ercon, and who does such work himseJl or IbrouGh IWo
own employees. provided Nl sucJI improvements are not intended or olIeted ror sale. If.
however. the building or improvement i.a sold wilhin one year of completion. lite ownt::r
builder will have lite burden of proYing Nt he did nol build or impmvc for pulJlO'l' of
Solie.).
o J, as owner or \he propcny, am exclusively contrxlinG wilblicensed contnelon 10
construct the project (Sec. 7044. Busi~ and Proressions Code:) The CoalnClDr's Lj.
ecnse Law does nal apply 10 .n owner or propcny who builda or improves \hercon. and .
l," Z f--:-=:-:==c::-:::==-:c===-=::-:-::-=:=:
• 0 0 LICENSED CON"ffiAcroR'S DECURATION
t -u I hcn:by amrm 1b.1 I am IiCl:nscd under proYisions or Cbapter 9 (commcndn;
~ '" wilb Section 7000) oroivi';on 30rlbe Businc.u and Proressions Code. and my Iicen .. i3 ~::l~ inrullroreean eeL 1Jp&-2B~
'0'" t:
1i:l ~ License CI Lie. , ---":~';:';;::;:;;:;:"76"'r-r0~~_.
;;:[;1 Date Conlraclor vet2CVJV•51-' ARCHITEcrS DECURATI~S'".... I undctsl3n~ my plans sIIall be uscd u puhlie n:cords 5~~ =... fool :L,..,.ic-cnse-d'"'Pro:-:rc-....-,-·o-nal-,----------------
40'" OWNER-BUILDER DECURATION~~~ I hcrcby 3llirm Ibot I am exempt from Il1c Conlt3ctor's Liecn .. Law ror the2-e::l1.00 rollowin; rcason. (Section 703!.S. Business and Proressions Code: Any cily or eounly ~~ff which rcquin:.s I permit to COftSlJ'uCt, aller. improve. dcmoJish. or n:pajr any SUUCtun:"-",prior 10 its wuoncc.. i&lso rcquires the applicanl ror such permil,a file asiG~ Slatement.2>
'hal he is licensc~ pur<uanlla the provisions of Ibe COnIt3CIOr's Licen .. Law (Chapter 9 ~i~
(commencinG wilb Section 7000) or Division 3 or Ibc Business and Proressions Co~) or~!:: 51
who conUlelS ror such projeCLS wilba conllaetor(s) licensed p""uantlO \he Contra<to(.
l.lccnse Law. o I am exempt under Sec. , B 8t PC ror lhi. rcuon
Owner _....".,===-=-:===-=====--=-= Date ..,.
WORKER'S COMPENSATION DECURATION
I hercby amrm under penally or pc1jury one or the rollowinG declarations:
o I ha ... and will mainllin •Certificate of Consent 10 selr·i...rc ror Workcr'sCompcn.
sation, u provided ror by Section 3700 or Il1c Labor Code. ror Ibe performance or lbe
won: ror which Ibi. permit is wucd.
o I have and will maintain Worker'. Compensation Insunnce, u rcqui~ by Sc<:Iion
37ooorll1c Labor Code. ror the performanceorll1c won: ror which Ibispermil" issued. MyWor~C~Itsa1lf" !luunnc;;~'~l/Policynumber1f::,"4 I~.t Carriu:LV~C!i-AHifL~NO.: ::!"; ~i j;2J)
CERTIACATE OF EXEMPTION FROM WORKERS"
COMPENSATION INSURANCE
(Tllhseetlon need nOlbecomplele~ iflhe permit is rorone hundrcd doll... ($100)
or Icss.)
I ceniry trulL in Ibc perrormance or the won: ror which Ibis permit is illSUCd, I sIIaJl not
employ any pe ...n in any manner so ulO become subject 10 Il1e Worltcr<' CompensationLaws or california. Date _
Appllcanl __-------_
NOTICE TO APPUCANT: II. alter malting Ibis Ccnificate or Exemplion, you sIIoul~
become subject 10 Ihc Worker's CompellSltion provisions or the Labor Code.. you mus<
forthwilh comply wilh such provmons or this petrnit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hcrchy amrm Ihai Ihcrc ;.. coll1lroClion lendinG aGORCY for Ihc performance or
the work ror which Il1i3 permil i1 Wucd (Sec. 3097, Civ. C.)
Lcodc(sName ~-------------Lcnder's Address _
I ccniry lbat I ha.. rcad Il1i3 appliation and slate Ibal Il1c above information i3
corrcCL I aln:c 10 comply .nib all cily and counlY onJinance.s and Slale la... relatinG '0
bUilding cOlLSlrUClion. and hen:by aulhorile represenQlives of lhis chy to cnLCt upon the
above·mentioned propcny ror inspection pUIJlO'l's.
(We) agree (0 sa"", indemniry and keep lwml.... Il1c CilY or Cupcnino a;ainsl
liabilities. judGments. costs expenses which may in any way aecrue alains' said aly
in consequence or Ibe nG or Ibis permiL
APPLICANT U STANDS AND WILL COMPLY WITH ALL NON· POINT
of ApplicanllContraelOr
SOURCE RE "TIONS.
Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or rUlun: building occupant stan: or handle laaz.ardous material
as defined by \he Cupenino M;rniciI Code. Chapter 9.12. and Il1c HcaJlb an~ Safety
Code, Section 2SSJ2(a)?
DYes No
Will lhc: applicant or (uum: building occupant usc equipment or cJcV(CC3 which
emil hv.ardou$ air conllminanLs IS defined by the Bay Area Air Quality Mana&Cmenl
O"tric,7 I /
DYes OXo
I ho.. rc~ Ihc Iaa7mlous malCrials rcqulrcments under Ch.apter6,9S or the Caliror
nil Heallb '" SaletyC ScetJons2SSOS. 2SS33 and2SS34.1 undcm.and Ihai ir the building
docs nol currcn~y YO a tenan~ Ihai il " my responsibility '0 notiry the occupant or the
rcquircmenlS w . h must be met prior 10 wuancc or a CcniflCa1C Jr;;' (J
OWDCr or aUlhorir..cd age"l
--'-----'I==I__.:::L=!-I-......!I==.I_---!I"===!Il....
J b .
0 Descnptlon
"2..
..QOMMERCIAL TI MINOR I~ERIOR MODIFICATIONS &
INSTALL NEW FOOD SERVICE EQUIPMENT @ (E)
LUNCHROOM
( 470 SQ)
1--------;:;--;:;--;:;;:---;--------,I----------;;-:-7""-~---~-----
Sq. Ft. Floor Area Valuation
42 00
O/l S Ot?1gwe"2 g t \.I 'V JU
Issued by:
Type of Roof
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 remov~
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class ':4" or better