04010077 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �Co,NT"OIT.bR INF, , orri�
BUILDINGADDRESS: _ MCLARNEY CONSTRUCTION PERMTTf4904010077
OWNER'S NAME: - PERMIT ISSUE DATE
LE BOULANGER RESTAURANT q nANTF.T. WAY
UP E: SANITARY 9 CONTROL NO.
4082468600
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
u 1 Mrcby.affirm Nat Tom licensed under previsions of Cbapmr 9(commencing Job Description
wuh Sa ion 7")of Division 3 of the Businentand Professions Code,and my license is
inrnnrnrceanderr«t. TI--NEW RESTAURANT .FOOD SERVICE
o Z Lleense class Lic.M
Date Cnatractor TEMP PERMIT #04050119 (EX. 06/18/04)
ARCHITECTS DECLARATION
1 ummum nd ery plans shell be used as public,..,do
DyU
;�t; Licensed Prudential...I
so
3 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
3:00 followingmnson.(Section 7031.5,Business and professions Code:Any city or county
X m� which requires a permit to eonnma,alter.improve.demolish.or repair any structure
M�'e prior m its ouumoo,alau requires theapplicant for such permit to file.signed statement
p�ps�s< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Va#'Ztgay922
a1F� (commencing with Section 71)(0)of Division 3 of the Business and Professions Code)or
Net he is exempt themman and the beau for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant ed a civil penalty ofr Occupancy Type j
not mom Nan five hundred dollen($500). 3 0 2 Qa
0 1,as owner of the property,or my employees with wage as their sole compensation,
will do Ne work and the swdum Isnot intended or offered for aau(Sec.7044,Business
and Profusions Cods:The Conummes License Law docs not apply to an owner ofAUG $ 2004 Required Inspections
propeny,who builds or i m proves thereon,actinium does such work himsel f or through his
own employees,provided Oatswh improvemenM=notinunded oroffemd fors de.If.
builder,the
avetebding rdenofprovingalt hewith
not year orcompletion,theowner- BU�LDIIV
builder will have the burden of proving that he did not build or improve for purpose of BUILDING sale.). /,aI—J
[03 1.as owner of the random,.m exclamly contracting with licensed centracmra to
construct the project(Sec.7044,Business and Professions Code:)The Conuaeter's Lt.
comes raw does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a eontracur(O licensed pursuant to the Contractors
License Law.
steeaemptu ,Bk PC ar thisreason
r.
Da
WORKER CO PENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the followin de mans:
have and will maintain aCenilicateof Consent he self-insure for Workeri Compere
cation.sw provided for by Section 37011 of the labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of Ne work for which this permit is issued. -
My Worker's Compensation Insurance carrier end Policy number an:
Cartier Policy No.: r
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need nottmeompleted if the permit isforom hundred dollars($101))
or fee,.)
1 rustily that in the performance of the work for which this Permit is issued.l shall not
employany person in any mannerm as to become subject to the Worlo rs'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making Nis certificate of Exemption.you should
become subject to the Worker's Compensation previsions of the labor Code.you must
foMwith comply with such provision or this permit shall 4 contend nn oked.
zaoCONSTRUCTION LENDING AGENCY
[-s (hereby affirm Nat more is a conswctinn lending agency for the performance of
the work for which this Permit is Issued(Sec,3097,Civ.C.)
QL coress
Leaders Name
L
D z ender's Add
VC) 1 cosily that 1 have mad this application and sum that fee above information is
Is, H correct.1 agree to comply with all city and county ordinances and sum laws relating to -
C V building construction,and hereby authorise representatives of this city to near upon sm
I$7 above-mentioned property for inspection purposes.
G (We)agree to save,indemnify and kap harmless the City of Cupertinoagainst ///���
h
liabilities,judgments,costs and cxanses which may in any way accrue against said City /
U in consequence or the granting of this permit.
^m APPLICANT UND STANDS AND WILL COMPLY WITH ALL NO -POI Issued by: Da[
CE REG / 1
\0 Re-roofs
Signatures Appli HAZARDOUS MATERIALS DISCLOSURE D - Type Of ROOF '
will Inc applicant or future builJing acupentstorc orhandle hmardous material
as defined by the Cupertino Municipal Conic,Chapter 9.12,and the Health and Safety
Code.satins 25532(a)7 ���sss All roofs shall be inspected prior to any roofing material being installed.
E]Yes g No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
l havardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Disuict7
❑Yes t
I have real the Weardtws materials requirements under Chapter 6.95 of the Colifory ',
nia Health&SafetyCodc,Sections 25505.2.57 J25534.1undcntandthmifthe building 4
does
not curteWlly hv. titi yrcspoi 'nility meodly thea upanl fNc
require mm�mnabe d t iaananne Ifinao:nrolenp cr. Signature of Applicant Date
owner amnnnveaagenl Dare All roof coverings to be Class "B"or better