07100125CITY OF CUPERTINO
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INk'URMA`CION�a
BUILDING DIVISION PERMIT
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Ccs n N Y..'IN
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BUILDI PSS
1Z��4% S DE ANZA BLVD
TBD - TO BE DETERMINED
PERMITNO.
07100125
OWNER'S NAME:
PERMIT ISSUE DATE
MOISON INVESTMENT COMPANY
01/03/2008
PHONE:
SANITARY NO. CONTROL NO.
CHITECDENGINEER:
BUILDING PERMITINFO
BLDG ELECT' MnECH
PIT
!� t I
LICENSED CONTRACTOR'S DECLARATION
lob Description
1 be achy affirm than, 1 am licensed unr provisions of Claim (cemm mos
with Section 70110) ofDiviskm 3 of the Rueineu arWprofc�ne Code, end my license is
in full force and effect 4 4
T. I . , WALLS, BATHROOMS & COFFEE BAR
Lkenre Cl Lk.g
Data I Conular &A fes•
ARCHITECTS DECLARATION
1 understand my plana shall W used as public rewards
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt form the Convinces License Law for the
following mason. (Section 703 1.5, Business and Processions Code: Any city or county
Which rtgotms a permit to enmtroc4 alcor, improve, demolish, or repair any stmnum
prior in its iauawe, also hapdrm the appliesm for such permit W file a signed Marmon
that he is RccmCd to the of dm Contractor's Urmar Law (Chapter 9
Sq. Ft. Floor Area
Valuation
Moment provisions
225000
(eommewing with Section 7000) of Division 3 of the Business and Proreselom Code) or
that he u exempt Wcmfrao and the bass for me alleged exemption. Any violNon of
3 5 9 17 0 6f Number
Occupancy
P Y Type
Sidon 7031.5 by tory applicant for a permit subjects Ne applicant o a civil penally ofN
not mom than five hundred dollen (5500).
0 I, as owner order property, Or my employees with wages a their sale compensation,
wiudathework.andlhaswnumisnatmmndedarartemdroraale(Sm.7o4t,Busiwa
Required Inspections
and Pmrenions Cade: The Committees Lice^ n Law donot apply m an owner of
ns
q P
property who buildsorimprevea thereon, and whodeessuchwarghimmlforthrough his
awnemployers, provided that such improvements are nmimmnled mofferW for We. IL
however, the Wilding or Improvement is mid within ane year of mmplesim. the owner.
builder will have dm burden of Moving that W did not Wild or improve for purpose of
ale.).
0 h as owner of the property, am exclusively convening with licensed contractors to
construct the pre*1(Sec. 7614. Business and Profaslom Code) 7W Contractures U.
rem law dons sot apply W an owner of property who Wilda or improves thereon, and
who Canmmce far ouch projects wIN a comnttnr(s) licensed Manuam in the Contractors
License Law.
0 l am exempt under Sec ,B&P C for this mach
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of PeOury am of the following decsradons:
I have and will method. a Cerdita a arconmm m.1114... m for Wmkers Compen-
.., u Provided far by Scro mi 3700 a the Laid, Code, for Ne perfo,mmw of the
rk for which this permit is issued.
`1 have and will maintain Worker's Compensation lmumme, u required by Section
3700 of the Labor Code. far the perfannmce of the work for which ths permit is laud.
My Workers Compenu . lm�mmm��f cartler and Policy number are:
Cartier. • rN01 Policy Nc:
. 1
—70�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tim section wed not be completed if the permit is franc hundred dollars ($101)
or len.)
I century that in the performance of the work for which this permit Is land, l bull not
employ any Damn in my ma inerm as In Wmme mbjmuo the Workers' Corownsation
Laws of California. Oats
Applicant
NOTICE TO APPLICANT: If, a ser making this Cenificam of Exemption. you should
bmome subject to IW Workees Compensation previsions of the labor Cink% you most
forlhwiJr comply with such Provisions or this permit mall W doomed mucked.
CONSTRUCTION LENDING AGENCY
I herehy affirm Jul mere iso construction Whiting agency far the performanceof
the work for which this permit s issued (Sec 3097, Cin C.)
Lenders Name
'
Lenders Addreas
I ramify last I have mad this application and sum Net the above infmmNon is
cortcct. I agree to comply with ail city and county eminerwes and sons laws mining m
building convection, and hereby authobm mpman adves of this city to enter upon the
.Ww-mentioned properly far inspection puipves
(We) agree to ave. Indemnify ad keep harmless the City of Cupertino against
limilifies, judgments, civ and expenses which may in my way accrue against aid City
in s mark.
Of to goonfing Of IND
APPLICe
ANTUNDERSTANDS AWILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURCE REGULATE) S.
Re-roofs
Type of Roof
,a? J k
���'n�-'���//.—
signature of AppliaHAZARDOU R Dam
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicantClupmtmfMun building mmpaptxore serandth
as defined by the Cupertino Municipal Code. Chapter 9.13, and the Health and Safely
Health Md
Code. Section 25532(a)?
❑Yen [w
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,agree to remove
Will the applicant or future building Occupant use equipment or devices which
.I
It hwourous air commrtments as defined by the Bay Area Air Quality Management
all new materials for inspection.
tric4
0Yes t
I have real the haamousmambasrequitimcr s under Chapmrb.95 refire Celrar-
niaHcalth&Sa@ly Cade Secd.MM5,25533and2553C.1.n . odthuiflW Wilding
dem amt currently hew • mnaL this it s my rapomibllity m..ory me.4.1 of the
requirements whichmuff et poor m issuance of. Certificate Of Occpmey.
Signature of Applicant Date
��37
All roof coverings to be Class "B" or better
Owner '
m
or authorized again Oakm