03080087CITY OF CUPERTINO
umLDwc mvlslory PERMIT
CQN`F CTbR INF , RMATI(!)1�1 a
"uCONSTRUCTION
BU I LDING ADDRESS:
SOUTH BAY COERMIT"°03080087
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ONER'S NAME:
PERMIT ISSUE DATE
CTC FUNDING. LLC
511 DIVISION STREET
_ E.
SANITARY NO. CONTROL N0.
(406)379-0400
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLOG ELECT PLUMB MECH
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LICENSEDCONTRd DECLARATION
9
Job Description
P
1 hereby affirm that I am licensed Br under provisions of Chapter (commencing
under
Bec Division3of the Busincse end Prufcssinm Codc, end my license is
with Sconce
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and
LifullforceClaand effect.
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NEW RESTAURANT 2140 FT. •JW�ISi�U•p1-A*YII,`V®e1T6/mope
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License Class
.SSI
Date Contractor
ARCHITECTS DECLARATION
—` I n mmnJ my plana aha he used es public records
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p44J�bO 1004
DEC�J L
�Tnsed Pror .v o�-b
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law lot the
Avi
following reason. (Section 7031.5, Business and Professions Code: Any city or county
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BUILDWA46V
which requires a permit to construct, alter, improve, demolish, or repair any structure
_
poor b) IN issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant mthe Previsions ofthe Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7") of Division 3 of the Business and Professions Co'der or
Oat he is exempt therefrom and Ne basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant u a civil penally of
3� i(ABI]hlT�er00
Occupancy
P Y Type
not more One five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their. sold compensation,
will do he work, and On svunure is nolintended m offered for sale (Sec. 7094, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
Required Inspections
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended incanted for sale. IL
however, the building or improvement is sold within one year of completion, the owner.
builder will have to burden of proving that he did not build or improve for Pon. of
and.).
ifd 1, as owner of the property, am exclusively contracting with licensed convectors to
to stmet the project (Sec. 7044, Business and professions Code:) The Contractor's Li.
cense Law docs not apply to an owner of propmy who builds or improves themon, and
who contracts for such projects with a comractoRld licensed pursuant to Ne Contractors
License I.
❑ 1 am exempt under Sec. B & P C far this reason
net Dare n ^ r/
WORKER'S COMPENSATION DECLARATION
I hereby or. under penally of perjury one of On folia in clsuxtimhc
❑ 1 have and will maintain a Coal Room of Consent to self-insum for Worker'aCumpen-
sation, as provided for by Section TIDO of the "her Code. for Ne performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
37M of due Labor Code, for the performance of me work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cameo Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
("this section need not be completed Tribe permit is for one hundred dollars (Slap
-
less.)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner an a to became subject o the Worker' Compensation
Laws of California. Date
Applicant
.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compcnsati0n provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm mat there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ, C.)
Lender's Name
Lender's Add.,
I certify mal 1 have read this application and some that the above information is
conal. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby aulherive representatives of his city to enter upon the
propene for inspection purposes.
above-mentionedCagree
(We) agree indemnify and keep harmless City of Cupertino against
.save,
udgmc and w
which may in any way accmc against said City
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in comcqu or thisexpenses
Aconsequence of the granting of this Permit.
the Pe
/
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE GULATIONS.
Re -roofs
Type of Roof
�S ^l��✓��'
Signewrc of ApplicanVCom Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant lir future building occupant store or handle hazardous material
as defined by the Cupeninn Municipal Code. Chapter 9.12, and the Health and Safely
Code, Section 25532(a)?
All roofs shall be inspected to an roofing material beim installed.
❑Yes No
prior
P P Y S g
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit du4sonus air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes %No
(have read me haradour materials requirement under Chapter 6.95 of the Califor-
nin Healh & Safety Calc, Sections 25505, 25533 and 255J4.l undem=d thmif me building
Jens not currently hove a tenant thal it is my responsibility to noddy the occupant or the
reguirel cmn ichmust se mel poor it) issuance of a Cerlicatc of Occupancy.
Signature Of Applicant Dale
��
All roof coverings to be Class "B" or better
er lir ata orireJ aFenl
Dale