05010112 (2) CITY OF CUPEW11NO
BUILDING DIVISION PFR,mrr CONTRACTOR INFO]WATION
BUILDING ADDRESS: ALLEN SIGNS INC PERMIT Nit)5010112
OWNER'S NAME: PERMITISSUEDATE
BAGEL STREET CAFE 1982 STONE AVE 01 /20 /2005
ONE: SANITARY NO. CONTROL NO.
(408) 280-6500
ARCHITECfIENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
±Oo LICENSED COMRACTOR'S DECLARATION
Iu C 1 hcrcby affirm tool 1 am licensed under provisions of Chapter 9(commencing I{� I�TM� escr Fption,
z,n wiNScmion)WU)urrision3of NC Ousincssarofcssiuns Cork.and myliccnsc is )y,•� � �hs F M
n
PDA
Or fan forte and elrec, 33 SIGN ttlf— a Y�`�a,
q i Limrac C _Lie.a_ r�
p Date 11 le rr�� Z`fU5
F)�U ARCH1lLCsS DECLARA ION FEBr �oo�
z< I undersand my plans shall he used az uh0c rcmrJs IB
a [i m
e.up t' Liccnscd Professional •I C Y F ^j
OWNER-BUILDER DECLARATION - p� p gg l hh
a S 1 hcrcby affirm that I ore exempt from the Contractor's License Law for the y } R 6nsn .a<5� it 6 4.'
00 following mason.(Schon](131.5.Business and Pwfcssions Cole:Any city or county V
2E which Inquires a Permit to construct.alter.improve,demolish,or repair any structure asi
Smi
prior to issuance.calm requires the Applicant for such Permit
He
a signed malemem
a bar In isIinmedpursuant nthe pmvisionsofthe Contractor's License Law(Cha pier9 Sq. Ft. Floor Area Valuation -
(commencing with Seaton 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therfrom and de boas for the alleged exemption.Any violation of
Section 703 L5 by any applicant for a Permit subjects the applicant to a civil Penalty of 3 2 GWI91S*ci0 0 Occupancy Type
not mom than B.m hundred dollars($500).
❑I,as owner of the pmpcny,0 my employees with wages as lheir.wle compensation,
will do the work,and Na suamurt is not intended or rrfemd for sale(Sec.]Ik4, Inspections
Required Business
and Pmresomms Codc:The Conlneoh Licenu Law docs not apply to an owner of Re q P
property whr builds or improves thereon,and who docs such work himself or Ihei 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 base the burden of proving that he did not build or improve for patinae of
sale.).
❑L as owner of the property,am exclusively contracting with licenud contractor in
nnstruct the project(See.70414,Business and Professions Code:)The COnmcnri Li
cense law docs not aPP1y to an owner of property who builds or improves tstmon,and
who ci maers for such Projects with o eonvamor(s)licensed pursuant o the Comment's
License Law.
❑1 am exempt under Sec. B&P C for this¢axon
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury are of Ne following declarations
I have and will maintain a Curt of Cou ht to self-insum fm WorkeesCompcn-
sation,As provided for by Section 3TW of Ne Labor Cedc,for the perform once right,
work for which this permit is issued.
u
lam'base and will maintain Worker's Compensation In....ax imp ired by Section
37W of the labor Code,fur the pmrormanc,of the work for which this permit is issued.
My Workera'sq Cnmpensaninm Insurance artier and Polity number am:
Carrier. Y V Policy No.:ODS�tX /
CCSKTION R _
FROM WORKERS'
COMPENSATION INSURANCE
Mis section need not Iccompleted if the Permit is for one hundred dollars(SIM)
or less.)
1 certify that in the perrormanee of the work for which this Permit is issued,l shall nm
employ any Persian in any manner to ax to become subject n Ne Workers'Compensation
laws of California.Date
Applicant
NOTICE TO APPLICANT:if,after making this CeniOcan of Exemption,you should
become suhjcct to the Worker Compcnamion provisions of the labor Code,you must
� fonbwiN comply with such provisions or this farm itshall he deemed mvoled.
7-0CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency lot he performance or
7r the wortk for which this pormit u issued(See3097,Co.Cr
y Q Under,Name
�,z Icaderi Address
J Q 1 certify that I have rad this application And sen that the above information is
S. U cording 1 agree m comply with all city and county ordinances and state laws relatingto
ve
�U abonngcojoned end hereby eutsoriamprescnmives of this City to enter upon Nc
y 6. alcvc-(We)Agree
1.sa property for impaction Purposes.
(We)agree ts cast,indcarc y and keep harmless the City of Cupertino agains6t`
rap incongrune of the coarsing ex penseswhich may in any way accme against said City
J A APPLICANT
NDts RSTANDS this permit.
•7 APPLICANT UNDfRSTANOS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
/y
SOUR UL ONS_g` `
—�I 11�/--l/.l)D- Q�O� Re-roofs .
Signanroof Applican Conuamor Dare
ZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tsc applicant or fmu,c building occupant nrrc or M1anJlc hazudous material
az de0ned by the Cupenino Municipal Cmfe.Chapter 9.11,and the Health and Safety
code.Section 15531(.)? All roofs shall be inspected prior to an roofing material beim
Ayes AN.
P P Y g g installed.
Will the applicant orfuture building Occupant use equipmentrrdcviceswhich If a roof is installed without first obtaining an inspection,I agree to remove
mit hz'rardous air connadmnu ax turned by de Bay Arca Air Quality Management all new materials for inspection.
District]
❑Yes 'ON.
I have read the hazardous materials requirements under ChaP er 6.95 of um Cahfm-
nia limits&Safety Cmle,SeNons 25505.15533 and 25534.1 understand that iflk building
does not c randy M1mc a¢rant,that it a my responsibility n anal y Be occupant of the L J
mqu' swhi muss melpdarraisaaanndoI.ccmfitrnofoceaP.rte Sign [ureofA plicant Date
owner ter aamnrive ag tet t 2 Date All roof coverings to be Class "B" or better