10050161CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20956 HOMESTEAD RD STE H CONTRACTOR: SMI
CONSTRUCTION INC
PERMIT NO: 10050161
OWNER'S NAME: 595 MONTAGUE AVE DATE ISSUED: 06/04/2010
OWNER'S PHONE: 4082553999 SAN LEANDRO, CA 94577 PHONE NO: (510)351-3288
LICENSED CONTRACTOR'S DECLARATIONo
License Class (3
Contractor SM I
Lic. #------->.8:~3--"---'lJ'---"'~oq,.6~ -
Date b
I hereby affirm tha t I am licensed under the provisions Cha ter 9
(commencing with Section 7000) of Division 3 of the B siness & Professions
Code and that my license is in full force and effect.
I 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 fue performance of the work for which this
permit is issued.
Signature_~;.<--+-----""-~ ---Date_---i'---'F-+_
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 prope or inspection purposes. (We) agree to save
indemnify and keep harmless th ity of Cupertino against liabilities, judgments,
costs, and expenses which rna ac inst said City in consequence of the
granting of this permit. A 'io ally, the plicant understands and will comply
with all non-point sour lati s ~the Cupertino Municipal Code, Section
9.18.
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OWNER-BUILDER DECLARATIONo
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, as owner ofthe property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
r r'BUILDING PERMIT INFO: BLDG ELECT PLUMB
rr
MECH RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: COMM'L TI BATHROOM UPGRADE ON EXISTING
RESTAURANT
Sq. Ft Floor Area: Valuation: $6000
APN Number: 32609061.STEH Occupancy Type:
Date: ? ";:7,.?t:?Issuedby~
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
RE-ROOFS:
All roofs shall be inspected prior to any roofing material beilg installed. If a roof is
1 installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
Signature of Applicant: Date: _
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Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I 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 fue 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 inany 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 Compensaion provisions of the Labor Code, I must
forthwith comply 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,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the awlicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
CONSTRUCTION LENDING AGENCY
HAZARDOUS MATERIALS DISCLOSURE
Owner or authorized agent: -
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. ~
I have read the hazardous materials requirements,..uoder Chapter 6.95 ofthe
California Health & Safety Code, Sections 2550 ,25533, and 25534. I will
maintain compliance with the Cupertino Mu 'cipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) sho d I store or handle hazardobs
material. Additionally, should I use equip t e lices which emit haiardous
air contaminants as defined by the Bay ir Qualit Management District I
will maintain compliance with the Cu Munici 0 ter 9.12 and
the Health & Safety Code, Section n 5534.
Lender's Address. _
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Protessional, _