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CITY OF CUPERTINO
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CONTRACTOR INTO MATION
BUILDING DIVISION PERMIT
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BulLDING ADDRESS:
EAST BAY REST SUPPLY INC
PFJAIRNO'05080169
19634 STEVENS CRK
OWNER'S NAME:
PERMIT ISSUE DATE
POTSTICKER RESTAURANT
49 4TH ST
12/05/2005
"NE:
SANITARY NO. CONTROL NO.
(510)465-4300
ARCHITECT(ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed undo provisions of Chapter 9 (commencing
with Section ?")of Division 3 of On Business And Profcssivas Code, end my license is
in full force and effect
REVISION --COOKING ORDOR FILTER SYSTEM
License Clme. a
Dam Licontrsent L rkr_
NO NEW PERMIT ISSUED/ORIG. #05010010
ARCHITECTS DECLARATIOW
1 undcrsund my plans shall he used as public records
Licensed Pmfassi... I
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following Mason. (Section 7031.5, Business and Professions Cale: Any city or county
which myuiras a Permit b mnstroet, &her, improve, demolim. Or ¢pair any Structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
that he ulicenscd pursuant o the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7") of Division 3 of ted Business and Prot miens Calc) or
$15 3
that An u exempt therefrom and Ne basis for flan alleged exemption. Any violation of
Section 7031.5 by any applicun for a Permit subjects On, applicant o a civil penalty of
APN Number
Occupancy Type
p Y YP
not mom Nan fmw hundred dollars (SSW).
❑ 1, As, owner of the property, or my employees with wage As their sole compensation,
will do Ne work. and the swcture at not intended a offered for sale (Sec. 7W, Business
and Professions Code: The Contravenes Liaise law doe Out apply in an owner or
Required Inspections
property who Wilds or improves thereon, and who doessuch work himselforNmugh his
own cmployces, provided Nat 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 haw the burden of proving that M did not Wild a "unprow for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors in
construct the project (Sec. 7014, Business and Professiom Code) The Coah.IM's Ll'
«me law does not apply to an owner of propeny.who Wilds or improves thereon, and
who contracts fa such projects with a comractor(s) licensed pursuant to the Como crow
License Law.
❑foto eaeminu ,B&PC far Nis moan
ar
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Ow,
w t" =rj K Date 6 �i
f WORKERSCOMPENSATIONDECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
an and will maintain a Ccnifiam ofConscm to self -in t an for WorkeriCompen-
As, provided for by Section 37M of the labor Code, fa the performance of the
work for which this permit is iuued.
❑ 1 have and will maintain Worker's Compeuauon Insurance. u mIuired by Section
""
of the LaturCode, for dm performance of On work for which this .I, u stand.
My W.,k,es Compensation Insurance canna and Polity number are:
Cartier: Policy No.: _
CERTIFICATE OF EKEMP ION FROM WORKERS
COMPENSATION INSURANCE
(Thu actuou need not W completed if the .it is intent hundred dnllus (SIM)
or mss.)
1 certify Nat in the performance or the work for which this Permit is issued. I shall not
employ any person in Any manner so u to become subjat en On Workers'' Compensation
Laws of Calii.roo, Dam
Applicant
NOTICE TO APPLICANT: IL after making this Ceraficam of Exemption, you should
become subject as dm Worker's Compensation Provisions of da, Labs Code. you moa
foMwith comply with such provisions at this Permit shall he deemed mooned.
CONSTRUCTION LENDING AGENCY
1 hereby Mo. that there is a em¢u e, inn lending agency far the pericam. of
The work for which this permit is issued (Sec. 3097, Civ, C.)
Lenders Name
Lender's Address
I certify that I have road this application arta sate that the above information is
COMM I agree to comply with all city and county ordinances and sate laws.].a.& to
building construction, and hereby sunbeam mpmaenenises of this city to tnmr upon the
almvcmcnutopeny for inspection purposes.
indemnify
(We) agree to save, and keep harmless the City of Cupertino against
and I.,.whichmay in any wayattsue apirmsaid City
judgments.the
in nst of the Sna this permit.
A
PLICA UNDERng STANDS
APPLICANT UNDE0.5TAND5 AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE, ��R_WuuLpp]]770 S.
17y e4POW 7t 12ilbTI05
Re -roofs
SgnuuresofAMIMIMUContracHO Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will On applicant or future building occupant store or handle haamous material
as delmod by the Cupertino Municipal Cade. Chapter 9.13, and On, Hcalth and Safety
.saeonsss3z(a)a JJJ
❑Ye pO No
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant esu equipment or dcvitts which
If a roof is installed without first obtaining an inspection, I agree to remove
hmardow air contaminants u defined by ted Bay Arta Air Quality Management
at,
all new materials for inspection.
Dyes ON.
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whi mit met puerto ismancemaCenificam of OccupPCY-
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Signature of Applicant Date
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All roof coverings to be Class "B" or better
Ownsrora h dam <dagem D.