04080159 CITY OF CUPERTINO *= F --
BUILDING DIVISION PERMITCONTE°ACTQR,z�INFORMATIQN - .-
BUILDING ADDRESS: PERMIT NO04080159 4080159
10591
OWNER'S NAME: PERMITISSUE DATE
SAM TAN BAGEL STREET
aE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u o o LICENSED CONTRACTOR'S DECLARATION.
I Mmby affirm that I am lianud under provisions of Chapter 9(commencingJob Description .. _
9zm with session 70)(B.I'Divisioa 3 ofdm Box.and Professions Coec..nd my Blew la - '- - �------- _ - ----
n« in full mreeand off=. TI--BAGEL SHOP
s'y_ License ClassLie.g
i-0 Dam Contractor CONTRACTOR: J L CONSTRUCTION (10/06/04)
ARCHITECTS DECLARATION
K I understand my plans shall he used as public rcenNs
p�
; Licensed Psufesconal -
3 OWNER-BUILDER DECLARATION
.�s f I hereby affirm shat T am exempt from tW Contactors License Law for the
-00 fallowing rtuon.(Section](IJ L5.Business and Profcsdom Code,:Any city or county
K m which reforest a permit to consumer,alcor.improve,demolish.«repair any etruerum
_i< prior to its issuance.also restj the applicant for such perraiuo fill a signed statement
that he is licensed pursuant o the provisions of the Contractors Liccnm Law(Chapter 9 Sq.Ft. Floor Area Xaljt�OOO .
y�O (commencing with Section 7/1(10)of Division J of the B ashen and Professions Code)or - r
i that he is exempt therefrom and the bas's for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects thc applicanuo a civil penalty of APN Number Occupancy Type
not mart Nan five hundred dollars($5(10).
01.as owner of she property,or my employees with wages as then tole compensation, 32610054 ' 00
will do the work,and the structure is not intended or onered for We(Sac.7064,Business
and Prefessiom Code:The Cmuro mrs License Law does at apply to.a owner of Required Inspectionsproperty who Wilds or improves thereon,and who does s«hwork himmlforthrough his
own employers,provided that such Improvements sal not intended oroRered for We.If. - ..
however,the building or improvement is sold within ane year of compleorm.the owner-
boldcr will have the burden of proving that he did not Wild or improve for purport of
h as owner of On.P pcnY,am exclusively contracting with licensed contractors to
c mwet the project 11jjeec'7044.Business a d Profmsions Cade:)The Contractor's Lt.
c tee law dots not,(hply to an owner of p Pent woo eilds or improvm thcmon,and _
who contracts for M1projeca wtha=on nar(s)li«used pursuanno the Cantradoh - - -
Licens law.
❑Into eaemp /der S«. ,B&PC for Nis rtuo
wrenIIA7
W K S tOA&PtNMndN MCLAIIATION
I hereby eRrm under penalty or perjury can of Ne following laxations:
I have and will mlfwm insure «
maintain a Cenof Cement to Wf- kee.Compen-
.u.n,as provided for by Section 37W of the IaW,Code.for the perfatman¢of the
work for which this Permit is issued.
I have and will maintain Worker's Compensation Insurance,as,required by Section -
37W of the Labor Cock.for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crux=am need not w completed if the Permit is future hundred dollars(SIM)
«less.)
1 unify that in Inc performance of the work for which this pcxmis is issued.T shall net
employ any person in any manneraa as to become subject to the Workers'Compemxtion
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making chis Ccnificam of Exemption.you shmW
become subject to the Worker's Compensation provisions Of the labor Code,you must
.JO foMwith comply with such provisions or this Permit shall W deemed revoked.
z'^ CONS RUCTION LENDING AGENCY
[- T hereby alarm that there is a construction lending agency lot the performance,of
f5 Be,work for whish his permit is issued(Sec.3057,Civ.C.)
W Q Undcr's Name
1
z Under's Address
J
V Q 1 ttsree Nu I have read this application and sum dust the salve information is
W f" =once I agree to comply with all city and county nNinan«s hal sum laws relating to
QU a1mve-gcotimacd .and hembyauNorpeoses.representatives of this city mentor upon Inc
W above-(Wer) gn, pentmrdmnifyadon keeph.
(We,)agrt m save,indemnify and keep harmless the City of Cupertino against
(A liabilid ajud ns,Coss an dor Panels w ch may in any way accrue against mid City �'
ing
V z APPL'CAen UNDERST(ANDSIAN�WILL COMPLY WITH ALL NON-POINT ISBUed by: Date
SOU E UL ON
4441zz4a lo.- 6 -0 Re-roofs
ram
gApp _
HAZARDOUS MATERIALS DI CLOSURE Dam Type of Roof
Will the applicant Lir future building occupant store or handle b.osA us material
as defined by the Cupertino Mumcipa ode.Chapter 9,13,and the Health and Safety
oder,Sccuon 255J1(a)? All roofs shall be inspected prior to an roofing material being installed.
❑res No P P Y g g
Will the appheant or mtare wilding«=spent use equipment or urvice,which If a roof is installed without first obtaining an inspection,I agree to remove _
a nms,oto air cortammams as d r d by N Bay Arta Air Q a ity Manag=mem all new materials for inspection.
District?
❑secs Nu
I have re o WrarAi
nus maalr" mqui-mens under Chap ter 6.95 of the Califon
Tia Health&Sof Code,Sections l5 5.85)3 and 15534.1 undeosWad thatifthe building
dam not carte ave a¢nam th u is an,responsibility to natil'y the occupant tf th
mttommenct h tic metp or as = Cmufic.mo U:ap err. Signature of Applicant Date I /
—J eV
caner or a a, t Dam All roof coverings [o be Class "B"or better