07120272CITY OF CUPERTINO
BUILDING DIVISION PERNIIT
�+g,iw':;»f
URMA`FiN
.,CUNTRAGTOR INFVu
Bu1f.Dip(avWpItESS
D DE ANZA BLVD
PACIFIC CONSTRUCTION &
P/fi8 272
vNNER'S NAME:
PERMIT 4$UO DATE
CIVIC PARK CUPERTINO LLC
1525 B ROLLINS RD
03/17/2008
PHONE:(650)
348-4800
SANITARY NO. CONTROL NO.
ARCHIECTIENGINEER:
BUILDING PERMIT INFO
BLDO EIJ:CT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
1 thereby affirm that 1 am limned under provisions of Chapter 9 (commencing
IOU Description
with section 700D)ofomirton3ofdu:Busineuand Profession, e,mdasylicea...
TT, NEW RESTAURANT MINOR STR CTURAL—AMICI' S
in full forte and offal
Lle, N
ConlDEC
QLD/ %ZL(�C�4J
Do.
Dau:
ds
ARCHITECTS DECLARATION
I understand my plans Mall o used u public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hemhy afErm that I am eurept from to Contractor's License Law for the
following norma (Secdan 71151.5, Business and Prmresdurn Code: Any city or county
which requires a permit w ennsoue4 aimr, improve, demolish, or repair my structure
prior he its iuunce. amu requires the applicant rarsoch permit to riile.signed namment
of the Coumaor's Vceom law (Chapter 9
$q. F[. Floor Area
Valuation
this o is licensed immanentm the provisions
(commencing with S.N. 7") of Division 7 of the Busilmuand Preftuions Code) m
$750000
1 that he u eaoopt therefrom and dm haat for the alleged memopUol Any vWalfoo of
,may yp} �ber
3 6 44 0 003
Occupancy Type
any
Sc come yartelidaaih„rs permit subject, Ilan applicant m s civil penalty of
dean five,
.AWL
❑ 1, u owner of IW Fop". a my uoployes with wyu u their sole comperation,
Required Inspections
will do the mark. and the a=in.isnotinmMeimonemd forsale(Sm. 7046. Business
and Professions Code: The Conlrscmes License Law does not apply m an owner or
q P
property who Wildamimpmves Ihereon.and whodoessuch work himselforideaugh his
awn employes, Provided that such improremmu sure not intended aroRered forsale. 11
however. the building orimpmwmmt at sold within one /ear or completion. the ownes-
Wilder will have the burden of proving dust an did nor Wild or improve ter puryax of
ale.).
0 I, u comer of the Property, sm uclusivelY conoacems MN Remount mnuuws to
construct the pmjecl (Sec. 7014. Business and Professions Code:) The Coauacmfs U.
core Law does not apply to in owmr of property who build, or Improves tharmn, and
who contacts, for sah projects with a conuanceKs) licensed pursuant m the Conuutoes
-
License Law.
❑ IrmeaemplunderSet .B&PCrar Mareuon
Data
WORKERS COMPENSATION DECLARATION
I hereby aOlon under Penally of perjury ane of the following decimations:
❑ I have and will maintain a Cerinesao'Consent in selRirumforWorker'sCompen-
urian, u provided for by Section 7700 of Use Labor Code, for the performance of tat,
work for which this permit is Issued.
❑ I haw and will maintain Worker's Compensation Insurance, u required by Section
3M of dm LsWr Code, for the performance or use work for which this permit is Issued.
'
My Workoes Compensation insurance eama dPaliry--n--uAAm--bee�r am�:� (/
Career ffC CIA�('�EO N'0:7F 7A�A- 000
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
mth, session need ml the completed lines, permit is fornme hundleddallan ($100)
or leu)
I certify that in the performaoo of tho work for which this Permit Is Issued, I Mail net
employ anypmaon In my numerso as in becume sobject to the Wmkers'Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT. If, ane, making this Cenifiam of Esemption. You Mould
became subject to ted Worker's Component provisions or the Utter Code, you muss
fanhwitb comply with =11 Provisions or this Permit shall ho domed Invoked.
1
CONSTRUCTION LENDING AGENCY
I Mmby afnrm Wt Wm H a mnstrecWn lending agency for Use perfm r mm of
Um work for which that permit is issued (See 3f197, Cis. C)
Lender's Nese
Lsnder's Address
1 mortify mal I haw lead this applicuion and sum this the shove information U
' norma I agree m comply with all city and county andiumea and sum lama misting to
Wilding mtturucdon, W hereby suthorim representatives of this city to nota upon Ifo
move -mentioned pmpcny for inspection purp=L
(We) agree in saw, indemnify and kap harmless tiro City of Cupenfm against
i liabilities, ludgranamcma and upemms which may In my Way seam sister, said City
in consequence of Ne granting of this permit
I APPLICA UNDERSTAN S AND WILL COMPLY WITH ALL N N -POINT
Issued by: Date
SOURCE UL(y{tONS. % i
y N '� �� i li a
Re -roofs
Type of Roof
Signuu mfA sanUConuacnor Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fuuuc Wilding occupantrom orhandle harardar mammal
as donned by tau Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
otic. sectio 25532(a)T
All roofs shall be inspected prior to any roofing material being installed.
❑Yeses
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fULium Wilding occupant use equipment or dcvioa which
emit hawmdmus air contaminants u del ned by the Bay Am, Air Quality Management
all new materials for inspection.
Dutnn7 If,�
Ely.kNNu
1 haw mW dm buadountstaiaatsequimmrnu under Chapmr6.95 orulm Califor.
.is Halth&Safety Cmde Secdmu 25505.25550 and 25554. I undcrsuim tMEtlte Wilding
des rant c haw a uman4 U at my rnporWMI1tY u mtifY tae of Um
mgaimmen hue timet nor ivumo ofa Certilleam cora
Signature of Applicant Date
All roof coverings to be Class'A:s' or better
Dam'
Owner or Nona dagcnt