08030099BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
2.091.6 HOMESTEAD RD TBD - TO BE DETERMINED 08030099
OWNER'S NAME: PERMIT LSUE DATE
08/29/2008
PHONE.` n trI -r-AAT SANITARY NO. CONTROL NO.
wRCHT[=1ENGINEER: BUILDING PERMIT INFO
u p p LICENSED CON'RtACTOR'S DECLARATION
V 1 ba=by affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 700M of Division 3 of the Business and Professions Code, and my Bcense is
in rull force arta effect.
LZ License Class LAC. •
= t DateContractor
ARCHITECTS DECLARATION
. 1 understand my plans shall be used as public necards
3'U
r, Licensed Professional
O OWNER -BUILDER DECLARA71ON
I hereby alTirm that 1 am exempt from the Contractors License Law for the
i in O following reason. (Section 703 U. Business and Professions Cade: Any city or county
IS V which requires a permit to construct, alter, hnprov=, demollsk or repair any stnctum
y prior to its'g«u•rk= also requires the applicant for such permit to file a signed statement
< that he is licensed pursuant to the provisions of the Contractor's Licensor Law (Gupta 9
C (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y R S that be ls exempt thueftom and the basis for the alleged exemption. Any violatlom of
Section 7031.3 by any applicant for a permit subjects the applicant a a civil penalty of
not mom than five hundred dollars (S500).
❑ L as; owner of the property, or my employees with wages as their sok compensation,
will do the work and the structure Is not inwnded or offered for sale (Ser. 7044, Business
and Professions Code Tae Contractor's License Law does not apply to an owner of
Property who builds or Improves thereon, and who does such work himself or through his
own employees, provided that such Improvements rte not intended or offered for ala B.
however, the building or Improvement is sold within one year of completion. the owner -
builder will have the burden of proving that he did nal build or improve for purpose of
L as owner of the property, am exclusively coatsaeting with licensed ctmtracters to
construct the project (See. 7044, Business and Professions Code:) The Contactors Li-
cense Law does not apply to an owner or ptopmty who builds or improves thereon. and
who contracts for such projects with a contractor(s) B=ased pursuant to the conurxars
License Law.
❑ 1 at exempt under Ser. B & P C for thip twos
Owner / )we 3 0
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty *(perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worlees Compen•
radon, 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 Workers Compensation Insurance, as enquired by Sado
3700 of the Lobar Cade, for the performance of the work for which this permit Is issued.
My Workers Compensation Insurance artier and Policy number am:
Cartier. Polley No.:
CENMCAT8 OF E CEMPTTON FROM WORKERS'
COMPENSATION INSURANCE
(This sectio need not be competed If the permit Is for one hundred dollars ($100)
Of est.)
Job Description
COMM'L TI BASKIN ROBBINS,NEW
EQUIP,PNTNG,DECRTNG,3CMP SNK,HND SNK,RLCT
FRNT&RER
CBNTS,TILE FLRNG
Sq. Ft. Floor Area
32609052:
1 certify that in the performance of the work for which this permit is Issued l shall not
employ any person in wry manner so at to become subject to the Wari Compens d
Laws of CalifordL tejr
Applicant D
NOTICE TO APPLICA . If. arcr maks g this Certificate of Exemp on yo should
become subject to the Workers Corepeosn don provisions of the Labor Code, you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
' CONSTRUCTION LENDING AGENCY
[� ... I hcnrby alfimn thatthere I. a construction lending agency for the perfomnirce of
a .: the work for which this permit is issued (ser. 3097, ch. c.)
OWm Q Lenders Name
z Lenders Address
U 0 1 certify out I have read this application and awe that the shove information Is
f7r " correct. l agree to comply with all city and county ordinances and state Levis misting to
0 building const cdon, and hereby suthmize represematives of Otis city to cuter upon the
W above-mentioned property for inspection PurPOSCL
(We) agree to save, indemnify sod kap harntks the City of Cupertino against
t..0 CA liabilities, Judgment, cops and expenses which may in any way airtime against said City
() APPLICANT UNDERSuence of the TANDS ANDng of thisDWWILL COMPLY WITH ALL NON -POINT Issued by:
_ /_ l
Signature of AppliadOContnctor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle haaardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Halth and Safety
Code. Section 75532(+)7
❑ yesNo
Will cine applicant or fu building occupant use equipment or devices which
emit hassrdous air contaminants as defined by the Bay Area Air Quality Management
DisWct7
❑ Yes IRNo
1 have read the hazardous materials requhcmcnis under capla 6.95 of the Caro,
nia Health & Safety Code, Sections 25505.25533 sal 25534.1 understand the if the building
does not currently have a tenant, taut it ls my .esM bility to notify the occupant of the
requirements which must be met prior to issuance of a Catificuc of
owner o thorned agcn Date
Re -roofs
Type of Roof
$22000
Required Inspections
Type
Date ?I "'p
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 remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class '%Y' or better