02050002 CITY OF CUPERTINO "
BUILDING DIVISION PERMIT CONTRACTOR INFORMATF`'N-
t
BUILDING ADDRESS: PERMIT NO.
10050 S DE ANZA BLVD 02050002
PP y
oy�wTMPTON GROUP AP05/ ills/2002
r ON�e SANITARY NO. CONTROL NO.
z ARCHITECT/ENGINEER:
p O BUILDING PERMIT INFO
s BLDG ELECT PLUMB MECH
6 i
L--:j o u L-A
5 y Z LICENSED CONTRACTOR'S DECLARATION
1hereby off NalIam.ftheBruderprovisions o(Cha de.r commmain Job Description
'_Cu�S with Section]000)of Division3of the Busine end Rvfcssions Code.end my license HOOD & REFRIGERATION
;y.5 ff
i50 !1—!2 - (RESTAURANT)
u w a il
Liexme CI Li X
1 be 60 t D=1� Con 1
J� CHITECf50E A I
yy g 1 undcmluna my plea shall be used as public records
r2 6f
i—p O Licensed Professional
o OWNER-BUILDER DECLARATION
uh n I Weby.(firm on 1 em exempt from Ne Csam, o License Law for IW
z a following reason.(Section]031.1 Business and Pro&emoli Cade:Any city st manly
which requires a permit to conswd,alcor,improve,demolish,or rtpeir any avucwm
i 3 .poor to itsissnsail p also requires Ne applicant(oration pemul to file s signed CammmL.
Nm heenlrog with
pursumnm the provisions of the the Business
License Law ons Cor)(coS t- Floor A ea-
orthin eingempttheSectrefoxon 00edthebasis a theaBpt!esvWpm.AnyvsCade? x, ('? 9' F- a. t . . 5 ,� •e; �", i' Valuation
or dw Section
7 31.5 b my spli an�the burs for the subjects
thetl applicant
t to Any violation -
-ofnotmn]ailnfive hundred cenlfar apermit 5abjecl5lne.pprc.nl la.avil penalty APN Number .
or not mare N,^five hundred aotlam(ssoo). Occupancy Type
❑1.a5 owner of the property,m my employees wdh..'as as Nm Sole aompermadon. 3 O 1 - ROUGH PLUMBINL
.will do the work,and the structure is aol intended or.Barad for sale sec.]Om, 303 - ROUGH MR II [ions
Business ad u m an Professions Code:The Contractor's Licenlaw does not apply
owner of property Who builds or improves demon,and who does such work himself 304 - ROUGH ELECTRICAL
Q
or through his own employees.provided that such improvements ore not intended or
`offered for sale.If,however,be building or improvement is sold within one year of 501 - FINAL ELECTRICAL ENERGY
completion,the owner-builder will have the burden of proving dust he did not Wild or
irnpmvcfarpurpmseofule.). 502 - FINAL PLUMBING ENERGY
❑I,as owner of the property,am exclusively contracting with licensed convenors to 503' - FINAL MECHANICAL ENERGY '
construct the project(sea.7044,Business and Professions cmc:)The Contnclor's 5 04 - FINAL BUILDING ENERGY
Littme law dmo clubs napply to an owner re
of property who Wilds or improves theon.
id who contracts for such Mijuts Ovid,a aonuarmal li<emd pueuml so the . . - 505 — FINAL- ELECTRICAL
ELECTRS CAL
conductors License law. -
❑lamexempt under So,. ,B&PCfar this season 507 - FINAL PLUMBING ,
ownb nate 508 - FINAL MECHANICAL
— WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declamations-
1 have and will maintain a Cby Sart er Conant tt uLabor for Worker's �tN
��'•� Coni.. on. he Provided for by Svdan P00 of the Labor Cade, for IW
�per(ormuntt of the work for which Nu pcmut is iuud.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section p
3700 of the labor Code,for the performuntt of Ne work for which this permit is gN•' Q , 2,0��
slued.MY workers Compcuaum Imuruwe c end Policy number arc: ka
_._. ,.'
This section ted not be completed if lha ._ ......__
(SI00)mlus.) p Permit i5 for one hurbeA dollars .
L'1 certifythat in the
. ..
shall not employ performance of the work for which this to
is issued,t' - -
p oy any f Cann in any manner u u ro become subjut ro Ne Workeri
Cop licam,on laws of California.Date
Applicant
NOTICE TO APPLICANT:IL CompanWng Nts Cemfi s ofmExcmpfionia,you oust
become subject y the Worker's Compensation permit she of the enWr Code,you much
z 0 fonhwiN comply Ovid such provisions or this pcmdl shall W dttmcd evoked.
CONSTRUCTION LENDING AGENCY
a ' I hereby affiant that them is a communion lending agency for the performance
of the work for which this permit is issued(Sec.3097,Civ.C) '
Leader.andv4..Q eader.Name ...• . .. . . . ' .
D.2a Aadrns' ..- - .. . . .
U'0 1 unify Net 1 have mad Nis city
bad on and sine that the above information is - a
tr-Ey eoried.1°gree m comply Ovid all city and county ordinances and sum norlaws roiling
V to Wilding commoction:and hereby authorise representatives of Ws caylo enter upon
>,,(g] theaWve-mmxkmd property for impaction puryo5cs.
F C6• (We)agree to save,indemnify and keep homeless the City of Cupertino agmina
r (A liabilities,judgments, is and expenses which may in my way accrue against said V V
V.2e City in sequeme of Ne grunting of this pemut.
APPLE UNDERSTANDS AND WILL FOMPLY WITH ALL N -PO
GIn.ATI� . v oS So Issued by: Date
Signnae M Apaliem ootravm - ase Re-roofs .
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant same Or handle hawaous material Type.of Roof
u defind by,tW Cupertino Mande i We,Chapter 9.12,and the Health and Safety Code. .
Cade.Section 25532(0? ,
0y. All roofs shall be ins ected riot to an roofing Will Ne applicant or fuiurc building occupant use equipment or devices which - p p y. g material.being.installed.
'nuneraraau5mamneininmtsseer1adbyNeBaynmaA;rQu,htyM.rmgement If a roof is installed without first obtaining an inspection,I agree to remove
�'""'E all new materials for inspection. Applicant understands and will comply with
Oyes o . ..
`all non-point source regulations.
1 have read Ne.,y Cmus matxaxdmals requirements under 4.1 an e6.9�rsu of Ne
Glifomia Heald&Safety Cde,Sections W05,25533 tI,isand 25334,1 understand the
if the Wilding attsn. currmdy have summit.dei it is my rupouibaitY m notify Ne
deco of do requirements which most W met prize to ismacce of•Card, a of
Oceu c�.'
Signature of Applicant Dale
net orroduamed.ga Re All roof coverings to be Class"B"or better
.,.. ...�.... _ .. .. -.:: -! -OFFICE
CITYBUILDING Dr DIVISION PERMIYS CONTRACTOR INN ORMA moi:
BUILDING ADDRESS: PERMIT NO.
10050 S DE ANZA BLVD 7 02050002
oyNrIMPTON GROUP APOS/ O15y2002
r•rONE: SANITARY NO. CONTROL NO.
caO O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�<i IJ O U L_.I
i zy m LICENSED CONTRACTOR'S DECLARATION
n oI heresy affirm that I am licensed under prov6mns of Chapter 9(commencing Job Description
•_t with Section 7")of Division3oftheBalm< and Pool,...on,Code.and my license HOOD & REFRIGERATION
is inmillnameet (RESTAURANT)
0 LiccnseCI /y Li
a.y _�I_—! Cant/ 1
< CHIN be use DF. A c
I undcrvantl my plans shall be used as public records
r
3 d C O
Licensed Professional
WLL
thri I. ax,m,tF.fr DECLARATION
I hereby affirm(lith 11. exempt from he Gonias Cov License Law for the
X?Mfollowing massa.(Section]onstruBusiness and
ve,deions Crdc:Any city orcoonry
z�e which requires a permit m lso mmst a ahec improve,demolish,or mash any tammerc
is.ca pro t t ' mianiurt theapplicantoff chile 'u tilessignedsmmmem- . .
mmhe sla'nsbdp rs e n7000)oprovisionsof me C t t es License Law(Chapter Com) S Ft. FIOor Area
mo m 6 mmsKr ]roan rheDivision3 lib Business dprofession,Any violation
�;7 'i i'�'trq';+ e `,: k ,{:y'.;1AF{ L'` Valuation
Or that he a exempt mcrcfrom and the basis for the subjects
th 8 exemption.Any violation -
-or not mo 703 n v any applicant for a pemat suDjecu ale applicant to a civil Penalty 7 - 00.
or not mart than fire hundred dollars(sstron. APN Number , • �' " Occupancy Type
°l,as owner of the properly,or my employees with wages as their sole compensation. 301 - ROUGH PLUMBI
wdl do me work;and the stmcture is not intended or offered for sale(Sec:700,,, - 3 0 3 - ROUGH M
Business ond'Professions Code.The Conmr
mc 's License Law it.,not apply to an 9CgdM4 i a6tlons:'.
oowner property Who builds or improves themar,and who due,such work himself
through M.own employeeprovided that such improvements are not intended or 304 - ROUGH ELECTRICAL
Offered for sale:If,however,the building ar imp o.emem is sold wohm ode yam or 5 01 FINAL-ELECTRICAL ,ENERGY
impown farPrwsaof aai will have me Ween of roving that he ata not build or 502 - FINAL PLUMBING ENERGY
°L-asawOe:dithe prrpcn,min esclu.veIyctier;airig with Icen:eAamarector.to- 503_ - FINAL--MECHANICAL ENERGY -
construct the project(see.7044.Budness and Precisions Code:)The Camrsamr 504 - FINAL BUILDING ENERGY
License Law does sol apply to as owner of pmpeny who Wilds lir improves thereon, '
-and.who.coommusfor such projects with a contracma.)ficcnutl.pormant to me. .. _.-_.. .,._.505 - FINAL- ELECTRICAL -- - --
Commaols License Law. ., '
m l am exempt under Sec. ` ' .B&PC for misrcaom 507 - FINAL PLUMBING
vinDate'' 508 - FINAL MECHANICAL
WORKER'S COMPENSATION DECLARATION
Phereby affirm under penalty of perjury are of the following declarations:-
O 1 have and will maintain a Certificate of Consent to ulf-insum for Worker's
.� Compensation, as provided for by Section 3700 of me labor Code, for the
performance of the work far which his pernil is issued, rt��InI�,�I t�
°1 have soil will maintain Worker's Compensation Insurance,as required by Section F 0 fs �+A L I s>s
r 3780 of the labor Code,for the performance of the work for which this permit is
issued Mry,w�ork r, C pe fon lnsum�ce/�r and Policy
Pol y be
6
2' ,:16 2•S 04t T1—t�
C[RTIFlCANOFEXEMPTION FROM WORKERS
COMPENSATION INSURANCE 4
-. ..
�g�rr }�ap�^
p perp �I WILlJ NG' .. -
'an tion licca sol lie oath lewd line r a for one hundred douse �„ r` ,_n;
ISIW) rlessJ -
' I'<n fy that in the performance ol me work for vNch this perm t x issued l -
shall net employ any person in any manner so
as to become cunlect to the Workers,
CmnMnsation laws of California.Data
-
Applicant
NOTICE TO APPLICANT If, ft king this Crffeme Of E-ampti you should -
Z become subject to the Workers C mpensil Provisions of me Labor Code,youmust
O C forth th comply with suchp 's s or this variant shall loadminedinvoked.
.. ._ .. ..._ ._..... ... .... .... __..... - _. .. - 1
CONSTRUCTION LENDING AGENCY "-
CG I hereby aFieh mat mere t i a o construction lending agency foi me performance ,
W
of work for Niche.permtis rssued(Sc 3897,Civ.C) -
D A -Lend N ... .. •.. ,..... .. _. .. .. ... _. _ .... _. ...
LcndksAtltlrcss - _ -
C.7 1 unify mar 1 have read alis application and sum mat the above laws o tali is j Q
Olas-F. carred 1 agree to comply with all city and authorize mpny emm�vees and scam laws relating
V mbuilding-menatmmionoperty rtbypectinpar,o enmtives of this city to enter noun
l� the ebocc-mcntinncd save,property for inspection and keep
p harmth.
. C. eWq agree to save,indemdify and whi h may in alt Ery a Cupertino against
W liabilities,judgments.costs and espenus which may in any way accrue against said
' V Ciry inc rsequencc of ale gmnting of this permit n
APPLx ,V� J'UNDERSTANDS AND WILLOOMPLYWITH ALL N N=PO T n
r R GULATI q. Issued by: Date
t '' b/e(IF T
Sigploomm A,11131U amracmr - � ' '3 m Re-roofs '
,HAZARDOUS MATERIALS DISCLOSURE
r
Will da,applicant or future building occupant store or handle harnraousarmcrial e of RPoof
do Cs o Cod Chapter 9.12.and m H Im d Safe,
Code.
oo. tl1S t 2532 )
°Yes - — - - -
No"
,All roofs shall be inspected prior to any roof ng ma[enal being installed
Will the applicant r b 'Id ll c p' til. q t t e 'tie wn n If a roof is installed without first obtaining an inspection,'I'agree to'remove
mithazad in - tazdr ell by the'BayA' q cut Mgame
all new materials for inspection Applicant understands and will comply,with
°Y '. `all non-point source regulations „'lt'�
1 M1 ve read ale h and .'.materials rcgv mommas and Ch-pl 6.95 of me - -
Califo Health&Safety Cod Sections 25505,25533 and 25534 1 understand the
ifine Wilding day not currently have a tenant,that it is my responsibility to notify the
Occup of me nequircments which muss W
It prior to issuance of a Cenific te of
Occup c _
�s� Signature of Applicant Date _
is auymd:<d agent " n All roof coverings to be Class "B" or better '
-OFFICE "-