08050167 CITY OF CUPERTINOy
BUILDING DIVISION PERNIIT �CCl1t1TRf�C�;t7I'INk'C}TtMrTION,014�'
.esu ^.Y"•R n.,a;F �. .,;. r^ u2..1 ,.1,
BUILgI G DRESS: - PERMITNO.
J�.SgS STEVENS CREEK BLVD #200 TBD - TO BE DETERMINED 08050167
NARME: PERMR ISSUE DATE
110MELAND MANAGEMENT GROUP INC 08/05/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
0 0 0 0
o a LICENSED CONTRACTOR'S DECLARATION
1t F I hueby of lana Nal I em Ikxucd under provisions of Chapter 9(commencing Job Description
'uj with Section 7000)
of Division 3ofthe Business andProreumsCode.and my[team Is T. I .NEW RESTAURANT SUSHI YA, E/M/P' S, SEWER,GAS,WTR
81 in full force and effect
�2 Licensu Clue Lie. r 6 0� LINES& EXHST&MAKEUP AIR SYS;NO RE-ROOF/NO
9 t- Dau 0 Co...rmmr
ARCHITECT-S DECLA, ION STRUCTURAL.
eL 1 understand my plana shall k used As public temrth
]yU
k tea Licensed Professional
7 5 OWNER-BUILDER m"a Ca"ION
9 C1 I hereby,firm Nm 1 em esempt from ale Cantracmh License Law for Ne
❑O following mama.(Section 70313,Business and R.dem ns Cale:Any city ser county
$ which its
n pmmit re e ices On.eller.improv,demolish,ri relay ed twcture
priaruiu issuance,also requires On applicmtfor such pennitm file esiguedsutemenl
�<
that he is licensedpurmantlotheprovisionsoftheContractor'sLica m aw(Chaptcr9 Sq.Ft. Floor Area $ Valuation
B (commencing With Section 70W)ol'Division3oftheBusiness and Professions Coda)or 130000
that he u ammpt dtertfrom and the basis for the alleged exception.Any viol Won of
Section 7031.5 by any applicant fm a permit subjects the appliesnt u a civil penalty of �p� umber Occupancy
satsame then fin hundred dallan(fs00). 23627035 .'ISG bT TyI)e
0 1,a owner of the property,ar my employees with"gas As their sale compevation,
will do the work.and the sma re luwt intended or aiered fa...I.fSes.7016,Bufinasa ns Required Inspections
ad Pmfeatans Code:The Contravenes Lae Lason at LAW t apply in m owner of q p
Property Who Wild.wimpeowathemon,and whodoesauhworkhimself orNough his
own employes,provided that such improvements are sat intended oraRered fosale.If. -
however,the building u improvement Is mid Within aro year ofcompletian,the owner. '
builder will haw On burden of proving that k did not build or improve for puryae of
ssleJ. '
1,as owner of the property,am exclusively Announcing with licensed mnoxmus N
mmwet the pnject(Sea 7044,Business and Pmfnsims Code:)The Contractor's U.
cense law does not apply in an inner of property who Wilds or improves di mon,ad
who contracts for such projects With aeonouurp)licensed puissant to the Contractor's
License Law.
❑I ann.umptundar See ,B&P C far Nis reasan
nor Dau
WORKERS COMPENSATION DECLARATION
I hereby allm under penally of perjury sate of the fallowing declantiant:
I ham and will maintain aCeNOau of Consent to Aslfdnmlm for Workr's Compcn-
salion,As provided for by Suction 3700 of the Labor Code,for the performance of the
wok for which this permit u issued.
0 I have ad will Austrian Worker's Compensation Insurace,As required by Section
3700 of the Labor Cade.for the pedamanm of the Work for which NO Permit is Issued.
My Worker's Compensation rInsun des,carrier ad Policy number an: _
Cartier. rSi)1+11 fwd Policy No.: {I25
CERTIFICATE OF EXEMPTION FROM ORKERS'
COMPENSATION INSURANCE
(Thbsectittn need not W Completed if the permit Is far enc hunthW dollar(gI0(1)
or lea.)
I certify Not in the performance of the work for which this Permit is issued.I shall net
employ any person in my matter As At becoma subjucl to the Workers'ComPensWan
Laws of Celifomia.Data
Applicant
NOTICE TO APPLICANT:If.After making this Certificate of Exemption,you should
kcome subject in the Worker's Campensmon provisions of the Labor Cada,you meal
.J O forthwith comply with such provisions or No permiuhall k domed revekcd.
CONSTRUCTION LENDING AGENCY
F I MrewY alfmi NU Nart ice.
Raei Q contraction agency for live Performance of
the Work for which this permt b Issued(Sec.3097.Chi.C)
Lerders
Name
]Z Lender's Address
U Q 1 cenify that I have read this Application and mu that the above Information is
ti.E contact 1 agree to cmnP1Y With all city and county ordinates and state lawn relaing N
O SV' Wilding canmuction,and hereby authoda upreunutiues of Nu city to enter upon the
W ahove-mcniumcd property for inspection purqusa.
gy (We)agree to taw,indemnify arW kcep handbus the City of Cupertino against
F-t W Iiabllitia,judgmenu.emu and expenses which may to my Way werue Against Asia City
in
O^
APPLICANT UNDERSTANDS ANDWILLWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
/ 9 48 Re-roofs
Signature of Appl.Xontncmr a Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof I�-
Will the applicant or future building occupant Rum orhandu haardons material
As droned by On Cupertino Municipal Code,Chapter 9.11,and On Health and Safety
s l Yen �,an 25532(&)7(.)?
❑ All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding occupant use equipment or devices which If a roof is-installed without first obtaining an inspection,I agree to remove
emit hoardons air contaminants As defined by Ne Bay Area Air Quality Management all new materials for inspection.
District?
0Yes Rj No
I ban mad the handws materials requirements undinChapor 6.95 of the Califor-
nia Health&Safety Cade,Sec6mu 75505,25533 and 25536.1 undersand thuiOhe Wilding
does not currently bane a unmL But it b my reepansibili y in notify Na amupmt of the
requtua milk mo prior to issuance,(.Ccnificew of Ocmpsacy.
a� Signature of Applicant Date
Owner or euthorived agem Dam All roof coverings to be Class'W'or better
G