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BUILDING DIVISION MIT
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BUILDING ADDRESS:
068 STEVENS rRREK
PERMIT NO.05070180
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0 Wff'S NAME:
PERMIT MUE DATE
JASON WANG /QUICKLY RESTAUR]LNT
01/06/2006
SANITARY NO. CONTROL NO.
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AIR HITECTIENGINBER:
BUILDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Section 7").f Dwi.km 3 Critic Business and Professhma Code, and my license is
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T.I.-NEW KITCHEN EQUIPMENT,
Lim no Lac, 0 ",-2 J
D11 Contractor
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TOILETS/ELECT/MECH UNITS ABOVE ROOF
A CHITOCTSDECLARATION
CONTRACTR: TOM'S CONSTRUCTION
I understand my plans shall he used as public necords
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby still that I am exempt firm the Contractor's License LAw for the
following region, (Section 703 1.5, Business and Pinfeasions Code: Any city or county
which requires A PCMIL 10 COnSmet, gun, improve, d(modim. Or MPsgr any &IMCIUM
prior w its issuance, also requires the applicant for such permit to file a signed stationce,
Connector's License Law 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the prevision or ft (Chapter
(commencing with Section 7000) of Division 3 of the Busimse and Professions Codc) or
,
$160000
Nat he is exempt doctrines and she basis for the alleged exemption. my violad on of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant 10 8 civil penalty Of
not ancre than thm hundred dollars (35001
❑ 1, as Owner of the property, or my employees with wages as their sale compensation,
3759:7846 ee-
Required Inspections
will do the work, and the muctum is not intended or offered for sale (See. 7044, Business
and Professions Code: The Contractor's License Law deal ad, apply in in Owner of
property who builds orimproves thereon, and who does such work himself orthrough his
Own employcia, provided nonsuch Improvements = not Intended Clarence for sads. It.
however, the building or improvement ismid within are year of completion. ft owner.
builder will have the burden of proving that he did not build or Improw for purpose of
sate.).
❑ 1, as owner of the property. am exchud"ll, contracting with licensed Contractors to
construct the project (Sec. 70". Business and Profusion Coulm) The Contiguou's U.
came Law does not apply to in Owner of property who bull& or tripmons tharcon, and
who contras for such pmjects with a coningtor(s) licensed pursuant in the Contractors
License Law.
❑ 1 am exempt under Sec. B& P C for this reason
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WORKER'S COMPENSATION DECLARATION
0.1
I hereby affirm under penalty of perjury did of race fallowing doelaratimis:
lin. and will maintain . Cerofficau, of Coolant to scIf-insurc for Worker's Compen-
an tion, as provided for by Section 37W of the Labor Code, for the performance of due
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which Nis permit Is hosing.
My Worker. Compensation Insurance carrier and Policy number ga:
Cartier: 4�9 Z. Policy N..:- ? 6 '? �
.,4 S
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissection wed notiancompIcted If the remelt is Forms, hundred dollars($100)
or less.)
I certify that In the performance of the work for which this ruing, is issued, I gull not
employ any pargin in any mannerso as to become subject to the Worlem'Compusation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT. If. after making this Certificate of Exemption, you should
become subject to the Worker', Compensation provisions of the Labor Code, you mug
fordiwith Comply with such provisions or this permit shall be deemed miniked.
CONSMUCIION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance, of
the work for which this permit Is isgund (Sm. 3097, Ch, C.)
Leader's Name
Lender's Address
I Certify that I have onal this application and gain that the &be" information is
coma I agree to comply with all city and County ordinances and Stan [am raising to
building construction, and hamby author oprestaffiadwo Of dill City 10 enter upon ft
above - mentioned property for Inspection purposes.
(We) agree to low, indemnify and keep harmful the City of Cupertino gi,siml
Hathifides, judipromm, costs and expenses which may in my way accow against said City
in consequence of die granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE RE LA
Re -roofs —(:7
Type of Roof
Applimrut/Corunxcl Dow
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fudum building occumid,tom or handle blood... mehirig
as delfrand by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Section 255320)?
All roofs shall be inspected prior to any roofing material being installed.
r1yes ON.
If a roof is installed without first obtaining an inspection, I agree to remove
1.xllll the applicant or future building Occupant use equipment in devices which
L ha/XdOUS air commitments as defined by the Bay Area Air Quality Management
all new materials for inspection.
0 yas ON.
16wncr
I have mad the huardousouncrialstmufterninins underChapmr6.95 ofthe Califor.
.is HgIdb& Safety Cad., Soction,255D5,25533 and 25534. lend.." dust if dm Wilding
does not tenant. dust it 4 my rupombility in notify the occupant of the
qu ramcnis which a em3cam or occupancy,
re I � met PE5 In'samt f c 113
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Signature of Applicant Date
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All roof coverings to be Class "B" or better
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