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CITY OF CUPERTINO
CONTRACTOR NFORMATION
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
EAST BAY REST SUPPLY INC
PERMIT NOO 5010010
ER'S NAME:
PERMIT SUE DATE
POTSTICKER RESTAURANT
49 4TH ST
08/18/2005
E:
SANITARY NO. CONTROL NO.
(510)465-4300
ARCHITECT(ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 Wroby affirm that 1 am Ilmved under provisions or Chapter 9 (commencingsis
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i
with Section ]IXIU) of Division 3 of Nc Business and Professions Code, and my license is
mmumraAnenBecr. Z
T.I. -RESTAURANT
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License azs" Lic.N
Dam con amr
BLDG A/SPACE E/1ST FLOOR
ITECI'S DEC
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I un rwnJ my plans WII W uud u PUM1Iic mrnr
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Canoed Profcssionel
OWNER -BUILDER DECLARATION'
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1 hereby affirm Nat 1 exempt fare the fesnmctor's License Law for IW
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following teas; (Section ] 1. Business and Code: city or count'
which require mean, mm. deoum
alms improv, demob ,.I,
fi repair any structure
permit re cores
r Z dam,
n the t
prior m its issuance, also requires the applicant for such permit so Ric s signal suwmcm
(One
incinvRLhSection7 the provisions ofthe too plincrrilitersUw(Chepmr9
Scaion]0110)tar Diaiionl ofIto and
ovilinJc) or
Sq. Ft. Floor Area g/r��q `'t 7n Valuation
5om
me Ire is exempt eretncss
on. Any
tlut W i eumpt IMrefrom and dw bei for the WegW exemptim. My violation of
rd/� ' $200000
f/i�Ta O
Section 7031.5 by any applicant for a Permit ubjects the applicant to a civil penalty of
than Five hundred dollars
APN Number44-N
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Occupancy ane e
//,: P Y TYP
not mom (5500).
B
orm emtode withmoa eueei(Sec. mm motion.
I,mmnerofthe Y P Y [ I
❑ pe
will do the won, and the he Contra tori Licaro,tended Law do for WE
someone a(Sec. ]044, Business
Prod ona Cade: The Law apply lf an ownar,
ton,
Required Inspections''
Property wh
property who builds wimprowath work himself or through his
vesthe and mh or is
end who
Own nt
intended
m, provided Nat such improvements are not ou
firer are m 9Rered for sale.Ir.
ver. th of
hander. the building arimprowmcnsissold within one year or completion. the owe
badder will haw IW burden of proving Nat W did nos Wild or improve for purpose of
of
talc.).
❑ 1, u owner of the propcny, am exclusively contracting with Iicenaed contracmm to
construct the pmjca (Sec. ]044, Business and Professions Cade:) The Contractor's Lb
cove Law does nm apply no an owner of property, who Wilds or improver thereon. and
who contacts for such project; with a commetor(s) licensed pursuant in the Contractor's
- -
Liceve law.
❑ 1 am exempt under Sec. B & P C for Nis reason
r Dam
WORKER'S COMPENSATION DECLARATION
- — - - - - -
1 hemby of irm under penalty of perjury, one of IW following decluationa:
1 bare and will maintain aCenifiam of Consent self -insure for Worker's Compcm
satin., u pmvid for by Section 3]00 of the Ll Code, for the perfarnance of the
- -
work for which this permit is issued.
❑ 1 bare and will maintain Wooer's Compcvation Insuru ce, u required by Section
3]00 of NC labor Code. for the performance of the work for which this permit is issued.
My Wormer Compensation Ins.... c/artier and Poliq numb,
Caere s".7�.Z� .L/Y l Policy No.:
6r
ntTE'If OFF MPTION FROM W as /
COMPENSATION INSURANCE
(Thi secure need.asbecomplcmd ifft permit is rmov hundred dollars (SIM)
or lass)
I century Nat in the performance of dw work for which this permit i issued. I shall not
employ any person in my manner m as to We.me subject o thr Worker' Compensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT: IL after making this Cenificam of Exemption, you should
baame subject m IW Worteri Compensation previsions of the labor Code, you must
foMwith comply with such prnvisiov or his Permit he] W dccmW rcwhd.
CONSTRUCTION LENDING AGENCY
I hemby Affirm use there is a construction lending agency I'nr the Performance or
IW work for which Nis permit is issued (Sec. 3097. Civ. C.)
Lender's Name
'
,
Under's Address
I certify Nat 1 have red this application and slam that the eban information i
correct. 1 agree m comply with all city and county ordinances and sole laws relating to
building construction. and hereby autharim minalm utiws of Nis city to toner upon the
liaove-mentionedproperty for Inspection FLO]POwhich
(We) agree to save• indemnify and hep hornless the City Of Cupertino agaivt
ms
may in any way accrue against said City
incoides. quenc oftheestaendexpcnaaswhich
in consequence or the gnntiof this Permit.
APPLICANT UNDER DS ND WILL COMPLY WITH ALL NON -POINT
Issued b Y Date
SOURCE REGULATI
vv 00 1411",cRe-roofs
Srgnaturc of ApumileWCOmmucto, t 'Date
HAZARDOUS MATERIALS DISCLOSURE
.Type Of Roof
Will the applicant w future Wilding occupant mom or handle haaardoue mawrial
fined by the Cupertino Municipal Codc. Chapter 9.12. and the Hcalth and Safely
. Section 12rSr
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding ..pan, um cquipmmt or Jcviccs which
If a roof is installed without first obtaining an inspection, I agree to remove
it hamrdous air contaminants as dcfinrd by the Bay Area Air Quality Management
all new materials for inspection.
"hic"
❑Yes lNu r
1have read the hvmdrwssma dalsrequimmenmun&rChapter6.95ofdw Califor-
nialkxlth&Safety Code Sadov25505,25533.d25534. Iundrimnd Nuirlhe Wilding
Jots not e-mmily ate a ton -L that it u my repovthility m notify the upant M the
'
id".C metpin issumee.r.CerdfiamorOc P er. /—
SignatureofApplicant Date
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All roof coverings to be Class "B" or better
oLwnrr or auihorind alfruL
INDOOR AIR DESIGN, INC.
9.2.2 NORTH 9TH STREET, SAN -JOSE, CA 951.1.2 - 2940
• (408) 289-9011 • FAX (408) 289-8018 • C-20, Lic#472788
*AIR BALANCE REPORT*
PROJECT: Pot Sticker - 19770 Stevens Creek Blvd., Cupertino, CA OS_ a) 00�
OUTLET # FC — I FC -,Z
1 1,1400 35U
2 1,500 240
3 200
4 34U
5 300
6 380
7 150 3.Zo
8 200
9 250
10 22S
11 200
12 22S
• 13 22S
14 350
15 IUU
16 2o0
TOTAL CFM 2,900 3, °I%S 01 0
NOMINAL CFM3,000 y,000 j 1 1 11
% OF NOMINAL '19-67-.. n_onoi� n nnoi n nnoi
1 -Equipment schedule FC -1 York fan coil model # _F4 Eu 12UA33,a --Serial #_ _ P VDsC? 42816
-------- ------------
1 -Equipment schedule FC -2 York fan coil model #F4q IzOa a3tt—� Serial # _ NooS°I428i8 .
2 -The bathroom is ventilated by a ceiling mounted exhaust fans. The 300 cfm fans are capable of at feast —�
10 air changes per hour
I, Edwin Lopez certify that these readings are true and correct. These readings were taken on
October 12th, 2005. 1 � an Alnor balometer to take the readings. listed in the table above.
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ENVIRONMENTAL RESOURCES AGENCY
FILE DEPARTMENT OF ENVIRONMENTAL HEALTH
"'-' -- CONSUMER PROTECTION DIVISION
cpunry or seem Clam_-� 1555 Berger Dc • Suite 300 • San Jose, CA 95112 • (408) 918 - 3400
SFax: (408) 259-5891 • Website: wvnv.ehinfo.org
REPORT OF OBSERVATIONS
DBA/NAMED •1y. I.
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ADDRESS LOCATIONr'
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RECHECK DATE
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