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CITY OF CUPERTINO �r
BUILDING DIVISION PERMIT
BUIL TNG ADDRESS: PERMIT NO.
1.265 STEVENS CREEK BLVD #200 TBD TO BE DETERMINED 08050167
O W K1E. PERMIT ISSUE DATE
HOMELAND MANAGEMENT GROUP INC 08/05/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB
MECH
O
u p Q LICENSED CONTRACTOR'S DECLARATION
W U
UU with Section 7000)of Division 3 of the Business and Professions Code.and my license is T. I .NEW RESTAURANT SUSHI YA,E/M/P' S, SEWER,GAS,WTR
E in full force and effect 4 ` O+J
� z License Class Lie.» Tlfr�7 LINES& EXHST&MAKEUP AIR SYS;NO RE—ROOF/NO
3 F p Dato 0 0 Contractor S r �
ARCHITECT'S DECLARATION STRUCTURAL.
< I understand my plans shall be used as public records
7yU
rC y Licensed Professional
n„3
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
COO following reason.(Section 7031.5.Business and Professions Code:Any city or county
(i which requires a permit to cnnstruct,aiter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
E_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
Y.h$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $130000
y`t that he is exempt therefrom and the basis for the alleged exemption.Any violadun of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of fignbTumber Occupancy Type
net more than rive hundred dollars(ssoo). 23627035
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that 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 have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's U.
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec ,B k P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of pedury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compcn-
cation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued
My Workers Compensation insurance artier and Polity number are:
Cartier. ST4+CJ F PolityNm.: 1125
CERTIFICATE OF EXEMPTION FROMWORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars($100)
or I=)
I certify that in the performance of dee work for which this permit is issued I shall not
employ any person in any manner so as to become subject to the Workcrs'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Campensadon provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked
z r"'' CONSTRUCTION LENDING AGENCY
[—r H I hereby affirm that there is a construction lending agency for the performance of
�.r the work for which this permit is issued(Sec.3097,Cir.C.)
WGL 0 (.enders Name
Z (.enders Address
U Q I certify that I have read this application and state that the above information is
t.24 r"'' correct.I agree to comply with all city and county ordinances and state laws relating to
0V building construction.and hereby authorize representatives of this city to enter upon dee
r U 0. above-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Hto liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. 6
Cl � t Re-roofs
f a
Signature oApplint/Contractor ,Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof �—
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section zss3z(a)? All roofs"shall be inspected prior to any roofing material being installed.
[3 Yes e,o
Will the applicant or future building occupant use equipment or devices which If a roof is,installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ON.
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health k Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my msponsibility to notify dte occupant of the
requirements hic must be m nor to issuance o a Certificate of Occupancy. Signature ofApplicant icant Date
q p A-LL4 . 5-, P6
horacd agent Date' All roof coverings to be Class'A"or better
Ow er or aut
OS0501 (P 7
-� CITY OF CUPERTINO
` TENANT IMPROVEMENT
CUPEQFINO PERMIT APPLICATION FORM
APN# Date:
�vtay zl 00
Building Address:
Mailing Address(if different from building address):
Owner's Name: � la�+d Man,aIK�� GPhone#: 208 g67. 7,919'p
b7c,
Contractor: Phone#: 6 S9 I 76 S/
� �t, arMi Fax#: 6to S9/ .276 2
Contractor License#: S-Q 3 00
Cupertino Business License#:
Contact: Phone#: 6 S0 $`9�, 76'l
N4 OM 0 M ��►� Fax#: 65-0 . ,5-9l. -2762-
Alternate
SO . .S9 . -2762Alternate Contact: Phone#:
Fax#:
Valuation (cost of project): 130000
Job Description(be specific):
(_-lJVI S L!2tG�i/�h g O) hew ,'IR- Hes L /^GS�i GLYillZ"6 .
S c-o p e o� wor�K ir�o�u q�,� its 'Iet✓
1,,�A f"e� �i rt e S � �7�1 sE Gx`'1�us� & /n•7 ke � �' S�"G Gt�,S,
Tenant Improvement Includes Re-Roof Yes❑ No ❑✓ If yes, number of squares
Tenant Improvement Includes Structural Yes ❑ No Z
Type of Construction(Usage Class): V,u Occupancy Type: B
1-A, 11-B ❑ 11, 111, V-A ❑ 11, 111, 1V V-B �
Project Size: Standard Lam" Large❑ Major❑
Green Building: Attach LEED Checklist to plans and identify in sheet index.
LEED Points Achieved:
*** For Office Use Only*** Over The Counter❑