04020112 CITY OF CUPERTINO t a
BUILDING DIVISION PERMIT ztN�VOa rRrAnm-O.,,
N-,
10
BUILDING ADDRESS: PEP MfFV48'0 2 0 112
1
OWNER'SNAME: PERMIT ISSUE DATE
2004
PHONE: SANITARY NO. CON7ROLNO.
CHffECr/ENGINEER: BUILDING PERMIT INFO
0 EO
PLUMB MECH
Lerz O
o O LICENSED CONTRACTOR'S DECLARATION
1 hereby affnm that 1 am licemetl under pravi.iev of Chapter 9(commencing Job Description
0:6 with Station 7IXD)mDivision3of the Bmineuand Profusimu Code.and my license;.
<< in full forte and cRem.
'q_ Liemen tae.« I--RESTAURANT UPGRADE
Date c°mECLARATION ONTRACTOR:
ARCHITECTS DECKR COMMERCIAL INTERIORS INC.
? < 1 understand my Pla1.1ull he used As public¢curds
u.� IMcen.ctl Pmfesaional
��v0ig OWNER-BUILDER DECLARATION
I I W-hy.farm that 1 Am mcmpi from the Convenor's License Law for the
E CI O fallowing mason.(Section 78313es
,Business and Profen mus Code:Any City or county
which requlrus A permit m consuum altar.W prove,Eemnlish,or mpair any seuctmc
Fly prior to i8 i¢uanegalmrequires the applicamforsuch pe Mail to rile a signed statement
E < Nnl he ie hecn¢d paRuenlln Nc
provision;of the Canlmctors License LAW(Chap¢f9 Sq.Ft.Floor Area M�4 �00
2 (commending with Section 7DOD)of Division 3 of the Business and Pmfcuiav Code)at Y
ell that he u saempt therefrom and Be basis fm the Alleged!esemmion.Any vWhui,a of
Ssc6m 7031.5 by any applicant for a Permit subjems the app0eml to a msdl Pemhy of APN Number
nm mare than five hundred dollars($500). occupancy Type
❑Las ownm of the pvpcny,ar my employees with vngesuNeir sole Comp31647019 . 00
will do the were,and Nwu
e selme not intended oroRered for role(Sec.7W.Benutlon,
uainees
And Pmfe¢iana code:The Cm, mars U.Law does am apply m an owner or Required Inspections
Propertywhobuildsorimproses Neeson,andwhodov.chworkhimselforthmugh his
own employee.,provided Nmsuch improvementa ate not Intended monemd fmule.IL
bowever,Ne building or impowernam is sold within omaYear of eompleuon,the owner.
Wild=will have the burden of removing that he did not Wild at Improve for purpose of
role.).
❑1,As owner of the properly,Am eaolmively competing with licensed contractors m
construct the pmjW(Sec 7014,Business and Professions Cade)The Contractors U.
sense law does not apply In an owner of property who builds or improves theater.and
who contracts for such pmjeeu with a cuntnnm(Q licensed pursuant to Ne Contractors U.M.Law.
❑Iamemmpt OMdef Set ,B&PCfm Mammon
owne Dam
TIO /
WORKERSCOMPENSATIONDECLARATION j
I hereby affirm under rectally of perjury cam of dta following dedantiov:
I have And prove a for by
•for37certificate of the Lab r ocir-haCode.
fm Wofkmance,a p.
me OC/
iiiiiiiiam, r phichti for by Se ssu T/00 of dta labra Coder.for the performano m Nc
Pink for which Nis peumft u issued.
0 1 have and will maintain Workers Compensation Insurance As required by Section
37W of the Labor Code,far the perfarmano of the work fm which this permit is issued.
MY Wmkers Cnmpevagon Ivor..carrier and Policy stomia:...:
Camra Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
to ICU.)(This Auction need not M Completed ifthn Permit is for one hundred dollus(S 100)
1 ConifY Not in the perfarmanm Mf thc work fm which this permit u leaned,1 shall not
employ any person!.any coammAn es m WCome subject m the WOrkw Compensation
Lawa of California.Date
Applicant
NOTICE TO APPLICAND If.After making this Cenifeme of Exemption,you Mould
berome subject to the Workers Compcmation pmvioons of Ne tabor Code.you tarot
.J 6 forthwith comply with such It v rnvisinor this permit ahall be domed mm ked.
'Zq CONSTRUCTION LENDING AGENCY
(+ IMeshy.bion that Nem Iso construction lendingagency for Ne forfurmmce of
ai the wort for which this permit is issued(Sec.3097,Ch,C.)
W�Q Lenders Name
z Lander'.Address
U Q I unify that 1 have read this application and Ne that Ne Uo c inform timA is
11.f+ cumem l agree m comply with all city and County omin uses and seta laws rehting N
0 building Construction.and hereby auNari¢¢pm¢nbtivus of this city mener upon me
above-mcmmnedProperty for finspetwon pugm¢n
(�yy (We)W¢C mama-indemnify and keep harmless the City m Cupertino against
yr y in caisequenc Of
mumd ospmues which may in any way gimme against mitl City
(,) in eansrq¢no of the gmnhng of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGULATIONS. '
Re-roofs
Stgmmre of Appb
HAZARDOUS MATERIALS DISCLOSURE D81C Type of Roof
WIII de applicant or future Wilding occupant sem or handle hnardous material
ss dcrined by the Cupertino Municipal Code,Chapter 9.12.and the Heslth and Safety
Code.SeNmsss32(.)7
[:1 Y. ONO All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
milvieharsnrdW.Urmntaminane As defined by the Bay Aro.Air Quality Management all new materials for inspection.
❑Y ON.
I Wvft MAl Ne haramnusmAwTiats¢quimmenBunderCWpmr6.95afNeCalifor-
niuRcalNg:SafetyCWC,Seniou25505,25533 arm25531.I underamrd Natif Ne Wilding
dors n n cummly have a Comm that it is my mspavihillly m rmtity IW ueeuPmt of the
myuircmenl which must W met Merl.issuance of a CemOne of Occupancy.
Signature of Applicant Dale
Owner or amhorimd agem DA1C All roof coverings to be Class "B"or better