04060039 77777�
CITY OF CUPERTINO
C®NTAT
BUILDING DIVISION PE 0 49 wdK j'9'M:-
N£o-J
i
J
LDING ADDRESS: PERMIT NOO4'0 6 0 0 3 9
n123 N WOT,FF RD 1044
NER'S NAME: PERMIT ISSUE DATEALAN WONGONE: SANITARY NO. CONTROL NO.
CHITECIYENGINEER: BUILDING PERMRINFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Op LICENSED CONTRACTOR'S DECLARATION
i�m lion 70arummalIamfthe uunderprovisionsofs Code, 9(mmmense is Job Description
ith fullto n]MeffecDivision3of the Business and Professions Code,and my license is
i^mumraanderreot. SIGN—DYNASTY SERF RESTAURANT
License Class Lic.b frr���
!w DaleContractor
I understand my plans shall ba usedas ��p�p��YYklEpd�
blic records �k p E®
ARCHITECTS DECLARATION
JnU
G y Licensed Pnafessinnal
OWNER-BUILDER DECLARATION DEC
0 0 1 hereby affirm shot 1 oro cxrmpr from thr Conuamm's ci Any
Law for my 1UUq
o O following meson. omit t ]1131.5,m.alter. and Improve,
derioli Calc:Any city s county
Km which rcquifes npermit re cnnaWm,alter,lmprosu ticmoa tt orerepair
aitgany tshemere
proton incensed noels.requires the applicant tforhe such inerrant rlca,Eno,(summcm
fro (comhot isccgwithSrsuanunmcpmvivision3ofdo,B sines ndproflaw(Chapur9 Sq.Ft. Floor Ar Valuation
x~n (cat he is(commencing with eefro]000)of Division of theeged exemption.
Any
Cmc)of
,Fn_ mos he u tempt tMrtrrom and the beau for me alleged eumptian.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3]P&BIQ`hfiB63er00 Occupancy Type
not moa man five hundred dollar,(1500). P Y YP
❑1.in owner drum,property,or my empki with wages as then sole compensation
will Pr thework,ands: is mitisowintene craw it f a.,u(Sec.]046,Business
pro Professions Code:Thr improve,
ist. nd he Law does or apply lb an owner is Required Inspections
property who b,provirimprovesthereon,andwho sum connotes work himsetfur mrougM1 his
ownemployers,provided prvemimprovementsarenot intendedmpleemd the oforside.r-
however.me building or den of proving that
sold within one year of completion.the owner-
builder will have Or burden of proving mal he did not builtl or improve for puryaa of
`sola.
1.as owner of Ina property,am unlusively aroaming with licensed rnnvaemrs m
co71strim,the project(Sec.1064.Business and Profusions Code:)Eric Contractors Li-
ccac Law does no,apply m an owner of pmpeny who builds or improves Bremer,and
who contacts for such projects wit a conuactorfO licensed pursuant m the Contra tors
Lucre.Law.
❑lames der Ec. ,B&PCf to as
net I
Da
WORK 4PE ION DECL ON
I hereby affirm under permlty of perjury arc of he tov declarations:
1 have and will mainuina CenNcom ofComeat m self-insure for Worker',Compen-
'on,na provided far by Section 3]00 of the labor Code,for the perfortnantt of the
k for wbicM1 mit permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as myuired by Section
3700 of the Labor Code.for the performuce ar the work for which this permit is issued. . .
My Worker's Compensation Insurance canner and Policy number art:
Carrier. Policy No.:
CERTIFICATE OF EKEM MON FROM WORKERS'
COMPENSATION INSURANCE -
Units seaia^need nmbm eomplemd if the permit Is future hundred dollars(SIM)
or less.)
I ttnify Out in the perfnrmana of the work for which this permit is issued,l shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Certificate ar Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
O mrmwith comply with such provisions or this permit shalt he deemed revoked.
Z CONSTRUCTION LENDING AGENCY
[-r I hereby affirm thin there is a construction lending agency l'or the performance of
Qithe work for which this permit is issued(Sec.3097,Co.C.)
W Q lenders Name
a z Lenders Address
f) Q 1 ttnify mal 1 have read his application and stale Nat he above information is
L, F-' comet.1 agree In comply with all city and county ordinantts and state laws relating to
O V building const 1ba,and hereby auhame represe^udvxs of this city to enter upon the
4L1 ahovomsJudgedproperty for cpectiom cn=purposes.
6. (We)agree to save,indemnify and keep harmless thr City of Cupertino against
U h In
limWuantl expenses which may in any way accrue againm tai Ciry
t)'Z in can cc of ting of this pC.,I.
^ APPL U ER AN ANp WILL COMPLY WITH ALL N N-P INTI Issued by: DZI' l
SOU U
Re-roofs
Signawrc of APP licanUCommcmrek
HAZARDOUS MATERIALS DISCLOSURE � Type Of ROOF
Will he applica^tuf turc buildingoccupantstorcor handle hmardous material
as der^M by the Cupertino nci otic.Chapter 9.12.and dr,Health and Safety
we,Section zs53z(')t
E)Yes u All roofs shall be inspected prior to any roofing material being installed.
Will me applicant or future building occupant Inc equipment or devices whim If a roof is installed without first obtaining an inspection,I agree to remove
ohn ci moos air a.nmmm,^tyas der, it by the Bay Area Air Quality Management all new materials for inspection.
❑Yes / No
I have mad Or hara fors materials requirements under Chapler6.95 of the C tire,
ria Health&Safety Coda Sections 05,25 an d25534.1urdersundthat the Idling
dos not currently h ran t r✓is immobility m noti y me xup -fire
regmnmjewhi m Fr i cps
Cenlrcar,�c % Signature of Applicant Date
1
rter awhod cd agent All roof coverings to be Class "B"or better
2411
14" �
fln
mz
m
J r $„
LA
S
Y,
ksS
N
O
On
�� J nCn < m n 0 -
S13
Z n
• • n Ocnn
S F N N Q
= x ; x. � �
9 (a Z(a88Z(
�nQo0o , o � o
b' 7Em
• (10
N N N•$0
3'� G)@D
_0 a
m m 2
r..a= -4 —+ o 00
N O (p 7
30
�.W 3ag p� Z � 35 f f
Mo
am � =Tg-%
= om
cD
o 39
o N M
m D w Z
o z r
o n oO Z
x� . o m
I
,•N. b _ b A D N Z � a \\ m
" p m
5
D C U ,u
A D
F � �
x
OITY OF CUPERTINO� 3 °�
CITY OF a
UPEkTINO PERMIT APPLICATION FORM
N # Date:
Building Address: ,/�
/o/a 3 Av- Z /,) �046 L 1'SD/,�4
Owner's Name: Phone#:
Contractor: / License #:
,C v c-& S6.vs 7 9 G 9/8'
Contact: Phone #:
7 X ,4-;
Applicant/Contractor:
Building Permit Info:
-Bldg Elect Plumb Mech
Job Description: -0v n/r}s 7-y :5 ei+-F oo �r=sravew�r
Residential: Commercial:
Sq.Ft. Floor Area: 0?
8/ $/Sq.Ft.:
17
Architect/Engineer: Cost of P�T'. e
�Nc�G(7A1/� LfJr✓STQVGT7DiV 1NC �
ype of Construction: Occupancy Grou .
A Ii le Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elect Permit issuance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Rmdl Si s, Mar uee ELECTRICAL
BUSLIC Business License BUILIDNG
•
•
"/
•
•
•
•
• s