08090002Cly OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
OWNER'S NAME:
ARCHITECTIENGMER:
u o a LICENSED CONTRACTOR'S DECLARATION
U I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z w with Section 7000) of Division 3 of the Business and Professions Code, and my license is
y in full force and effect.
Z License Class Lic. H
'n F Date Contractor
ARCHITECTS DECLARATION
LL I understand my plans shall he used as public records
7aU
m F Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
n O following reason. (Section 703 1.5, Business and Professions Code: Any city or county
K $ which requires a permit to construct, alter, improve, demolish, or repair any structure
n y prior to its issuance, also requires the applicant for such permit to rile a signed statement
x G that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
H (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
1. that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
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
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.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors 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.
❑ I am exempt under Sec. B & P C for this reason
415)643-5200
Job Description
REVISION—PUT TRANSFORMR ON DECK—POPEYES,./BURGER
KING; ORIG#08050113—NO NEW PERMIT.
Sq. Ft.
31620100.FC5
Owner Date
WORKER'S 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.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier.Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is forone hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 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
,z forthwith comply with such provisions or this permit shall be deemed revoked.
0 CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
7 the work for which this permit is issued (See. 3097, Civ. C.)
W A fender'Name
z Lender'ss Address
U 0 I certify that I have read this application and state that the above information is
LL H correct. I agree to comply with all city and county ordinances and state laws relating to
0 U building construction, and hereby authorize representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
tH liabilities, judgments, costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by:
SOURCE REGULATIONS.
Signature of Applicant/Conlraclor 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
Code, Section 25532(a)?
❑ Yes ❑ No
Will the applicant or future building occupant use equipment or devices which
emit hayardous air contaminants as defined by the Bay Area Air Quality Management
Districl7
❑ Yes ❑ No
I have read the hayardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Dale '
Re -roofs
Type of Roof
Area
Required Inspections
C-41114 6, rt
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection. .
Signature of Applicant Date
All roof coverings to be Class "{'' or better
PERMIT NO.
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PERMIT ISSUE DATE
A
CONTROL NO.
BUILDING PERMIT INFO
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ELECT
PLUMB
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Job Description
REVISION—PUT TRANSFORMR ON DECK—POPEYES,./BURGER
KING; ORIG#08050113—NO NEW PERMIT.
Sq. Ft.
31620100.FC5
Owner Date
WORKER'S 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.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier.Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is forone hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 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
,z forthwith comply with such provisions or this permit shall be deemed revoked.
0 CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
7 the work for which this permit is issued (See. 3097, Civ. C.)
W A fender'Name
z Lender'ss Address
U 0 I certify that I have read this application and state that the above information is
LL H correct. I agree to comply with all city and county ordinances and state laws relating to
0 U building construction, and hereby authorize representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
tH liabilities, judgments, costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by:
SOURCE REGULATIONS.
Signature of Applicant/Conlraclor 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
Code, Section 25532(a)?
❑ Yes ❑ No
Will the applicant or future building occupant use equipment or devices which
emit hayardous air contaminants as defined by the Bay Area Air Quality Management
Districl7
❑ Yes ❑ No
I have read the hayardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Dale '
Re -roofs
Type of Roof
Area
Required Inspections
C-41114 6, rt
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection. .
Signature of Applicant Date
All roof coverings to be Class "{'' or better