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06120070CITY OF CUPERTINO BUILDING DIVISION PERMIT g� 7�T ��g "gg ��������� �17���1tl8A�Y��'. BUILDING ADDRESS: PERMIT NO, OWN A PHo PARK AVE STE 200 -104TA@y&0.2 0 0 7 CONTROL NO. ARCHITECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 70(K)) of Division 3 of the Business and Professions Code, and my license is in full force and cff— REAT A FOOD SERVICE & VENDING AREA IN ADDITION License CLas s_.��� Lie. q _ Date Y� t1 "�-" Contractor C 6W4�c�_(' ARCHITECT'S DECLARATION TO A REMODEL OF MULTI PURPOSE ROOM I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code. Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance. also inquires the applicant for such permit to file a signed statement Sq. Ft. Floor Area Valuation that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 70D0) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number ceupancy Type Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of not more than rive hundred dollars (S500). 1, asowncr of the property, or my employees with wages as their sole compensation, 31619061 .00 Required Inspections will do the work, and the structure is not intended or offered for sale (Sec.7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of 9 P property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's , License Law: ❑ 1 am exempt under Sec . B & P C for this reason Owner Date WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 370D of the Labor Code, for the performance of the work for which this permit is issued. ' My Worker's Compensation Insurance and Policy nnuum7be sue/ Pr �y �^����� lcarrier Carrier. �'�I r✓''� l��-ll PolityNo.: < CERTIFICATE OMIMWPT1ON FROM WORKERS' COMPENSATION INSURANCE CThis section need not be complcled if the permit is for one hundred dollars(S 100) or less.) 1 certify that in the performance or the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that 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 Address I certify that I have read this application and state that the above information is correct. I agree ro 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 shove -mentioned property for inspection purposes. (Wc) agree to save, indemnify and keep harmless the City of Cupertino against li abili ties, judgments, costs and expenses which may in anyway accrue against said City in consequence of the granting this permit. Sf APPLICANT UNDERSTA S AND WITH ALL NO -POINT �, Issued by: Date — 7 7 SOURCE RE TION . !�OMPLYL Re -roofs .� Type Of Roof '� Signature of Applicanl/Contractor ._ _ — _ Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Cotic, Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes J7�f4o 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 hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yesu I have mad the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Code, Se ' ns 255i 533 25534.1 understand that if the building does not currend a nano that i ' Amy ponsibility to notify the occupant of the rcquircmcnt , in be met p' o iss cc a Cert ficate of _ Signature of Applicant Date All roof coverings to be Class "B" or better wncr or authorircd agent Date