05120141CITY OF CUPERTINO
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4 CONTRACTQR INF,�ORMATION„
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMR N0.
05120141
O E:
PERMR' ISSUE DATE
NE:
SANITARY NOS L NO.
ARCH1=1ENGINEER:
BUILDING PERMIT INFO
BLDG EIJ?Cr PLUMB MECH
LICENSED CONrRACIOR'S DECLARATION
Job DCSCfIpt100
1 hereby affirm that I am liaemed under Pmvisiam of CMPter 9 (commencing
with Section 7W) of Division 3 ofm, Business and Pnerassiom Coda. and my license is
in full force and eff=L
uaaseclass Lle.•aI43elll
—31�
T.I.-BLDG/ELECTRICAL/PLUMBING/MECHANICAL
DamConlreclar .
ARCHITECTS DECLARATION f
A2 OCCUPANCY -CHUCK E CHEESE
I undersand my plans shall be used as public records
Licensed Pmrcssional
ON
OWNER -BUILDER DECLARATION
the omeaaCo license taw for the
Comm
1 hereby .sere that 11.
,exempt sinfrom
following .neon. RD 1,5, Business and P r Calc: Any city or caumy
. dcroli
which nquisu a ummit to dcmali m sig any
re cnnuroca iltu. norapplicant
e. also rot such I e a summon
ucenena,alamptto s theNovisiosof roe suchpcmttwcanse Lted sumen9
Sq. FL Floor Area
Valuation
thanWor
of the eBusicmrond Prollaw(Chapter9
pSection tolhc of Division
Diviion3 or the Business andm Anyvi Cattle) or
(eat
that he u evunpt Ourt(mm and ale baso for the illcgrd eumpdom Any violation of
heisingwtthsutton and the
APN Number
Occup y pe
SeNon 7031.5 by airy applicant far a permit subjects the Applicant a civil Penalty of
not mom Nen five hundred dollars (5500}
❑Lasowna or the my eruplryeum.wage uNe'v a
316 2 0 0 8 3 0 0 Required Inspections
.Burridon,
thopary,or
will do Nevmdt end titostruaumunotkLMed (Sec.
sale(Ser.an.
matter
and Proressiom coda The Conuctart License law dao rot apply m an owmr or
Law does
.
property who builds or improves thereon, and who does such work himself m through his
emauartmyearrofcmoRercd for sale. If.
ownemployca,progor tot
idotoven
however, Ne building or improvement u sold within ane year or completion, the ownaf
is
butlda will Nva the burden of preying that k did rot Wild m improve far puryose of
oak.).
❑ 1. u owner of the property, an eaelusively contracting with licensed Convenors an
cense the project (Sec oars, Buri•..s and Code) The Caaheaors U.
C
Law drca tot apply m an owns or pmelons who builds or improves thereon, and
La es property who
/
who
who. contracts rue ¢mM1 projccta with a eonvacmr(a) licensed pursuem m she Conuanor's
License tow.
�6
❑Lem eacmpt under See .BBPCfor Nis reason
owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty of perjury am of the following dalaadons:
1 have and will maintain a Ceruli am of Cotuent to self insure fm Workers Consen-
sation, as provided for by Section 37DO of the labor Code. for the performance of the
work for which this pumit is issued.
❑ 1 have and will maintain Workeri Compensation Insurance, as required by section
3700 of de labor Code, fm Ne performance of the work for which this permit is issued.
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My Worker's Compensation losIs1ursna artier and Policy numbbeerr am:
-
Carticr,!/xVCI« i1t16PreNi1./Polity No.: till {s�uss_s✓-a
CERTIFICATE OF EXEM101MON FROM WORKERS'
COMPENSATION INSURANCE
(rbuseNon used net he completed if Ire Permit Is (mom hundred dollars (5100)
or rasa)
I certify Nor in Ne performance of the work Ire which this Permit u iumd, I shell nor
'
employ any person in any matter m as to become subject the Workers' Compenaa0on
Laws or California Dau
Applicant
NOTICE TO APPLJCART: IL after making this Certificate of Exemption, You should
became subject N the Women's Compensation provisions of the Labor Cade, you must
foMwith comply with such provisines or this Permit shill he deemed revaked.
CONMUCT1ON LENDING AGENCY
that Vert is a eomuuctint lending agency rat dx Performance of
dto work fur which this permit u issued (Sec. 3097, Civ. C.)
lender's Name
Lenders Address
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I cad(y that 1 have rad this application ars sou than the above information u
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correct. I agree to comply with all city and county oNinnmeS end auto hws relating u
building construction. and hereby sudborim repmsenudves of Ni city 10 emu Upon the
shove-mcnriancd property, for impaction phich s
(we) agree m ave. Indemnify and kap harmless the City of Cupertino against
I.abilttla,Jud menu, emu andeapensn which may in any way accrue against aid City
too ret of the sand g of this permit.
APPL A VNDERST DS AND WIL COMPLY WITH ALL NON -POINT
SOU
Issued by: Date
E ULATIOI
Re -roofs
Type of Roof
,11r,pure of Applsc HAZARDOUS MATERIALS DISCLOSURE havaer Dau
Will du applicant of Puttee building oce.parat slope m handle havaml material
defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Schon 25572(,)1
❑m
All roofs shall be inspected nor to an roofing material being
P P Y g g installed.
Will the applicator or future building occupant use equipment or device which
If a roof is installed without first obtaining an inspection, I agree to remove
niI horatdous air co arodam s u dapped by 'be Bay Ara Air Quality Management
all new materials for inspection.
District?
[3 yes Lynn
1 have mad the hvudtws matoriai mqutmmcros uncerehapser 6.95 of the Califor.
tie Health k SaferyCeem Sections 25505,25533 and 25534.1 unda¢mnd Naz it the building
does ter a nt1Y ham a tomo Nat it u my responsibility N nodry the occupant of Ne
mgol awhichm xmerptiaraissuanaOra ccrorwarearaeepncy.
Signature of Applicant Date
S — —9
All roof coverings to be Class "B” or better
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W r tar awn ser agcm Dam