B-2016-1929 CITY OF CUPERTINO BUILDING PERMIT
BOILDINGADllRCSS: CONTRACTOR: PERMITNO:B-201fi-i929
10310 S DE ANZA BLUD COPERTINO,CA 95014(369 55 O81) OMEGA
CONSTRUCTION
SAN JOSE,CA 95117
OWNE2'SNAME: CNICPARKCUPERTINOLLC DATE ISSUED:OS/ll/201C>
OWN�R'S PI�ONE:408 355 0090 PHONE NO:(4�8)fi05-BllJ
Li E ED R R DE LARATI BUILDING PGRMIT INPO;
License Class� Lic.#586016
Contractor OMEGA CONSTRUCTION Date 01131l2018 X BLDG _ELECT _YLUMB
MECH RESIDENTIALXCOMM�RCIAL
I hereby af�irm tlwt I am licensed m�der[he provisions of Chnpter 9(commencing — — —
with Section 7000)of Division 3 0l'lhe Business&Prafessions Code and that my
license is in PoII force nnd effecA JOB DESCRIPTION:
T.I,PREP-DEMO(E)PIZZA O V EN,KITCHEN EQUIPMENT,NON-
I hereby nftirm under pennity of perJmy one of the following M�o declnrations: LOAD BEARING WALLAND COi7NTERTOP(T.I.PEI2MIT#B-2016-
i. 7 havo nnd will mnintani a cerfi6oa[c of conseut to solf-i�isure fm�Worker's 1802)
Compensntion,as provided For by Section 3700 a£tlie Labor Code,for[he
perFormance of the work for wliich Ihis permit is issued.
z, I havo nnd will maintaiii Woiicer's Compcnsadon Insurance,as provided For by
Seo[ion 3700 of fhe Lnboe Code,for the perfonnence af�he work for whioh thia
permit is issucd Sq.Rt Rloor Aren: Valuation:$3000.00
APPLICANT CERTIRICATION
I certify that I have read this application and state that the above
. information is correct.I agree to comply with all city and county ordinances APN Nnmber; Occnpxncy Type:
and state laws relating to 6uilding construction,and hereby authorize 369 55 081
representatives of this city to enter upon the above mentioned properry for
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which pERMIT EXPI�S Ir WORI{IS NOT START�D
may accrue against said City in consequence ot the granting of this permit. W jTHiN 180 DAYS OP'P�RMIT ISSUANCE OR
Addltionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municl�al Code,Section 5.18. 1S0 DAYS FROM LAST LL�D INSPECTION.
Signature �ate 0 2016 Issued by:PAUL O'SULLNAN ��.1,.�,��
Dnte:OS/11/2016
OWNER-BUILDCR DI�:CLARA'CION
I horeby aYtirm thv[1 nm exempt from tho Contrnetm's Liconao Lnw for one of the RE-ROOPS:
f'allowing bvo reasons, All rooFs shall be inspected prior Io any rooling material being installed.I£a roof is
i. I,es owcer of tlie property,or my employees with wages z�s tlieir sole mstalled without frst obtaining an inspeotion,I agree to remove nll new materials for
compeneation,will do tlio work,and tl�e atractare is not intended or offered for inapection.
sale(See.7044,Bnsiness&Professious Code)
z. I,ns owner of flie property,am exclusively contruc[iiig with licensed Sigonture oCApplicnnt:
co�i�ractors to conshzmt the project(Sec.7044,Business&Professiaiis CaAe). Date:OS/1 U201f
I hereby afFrm under penalty of'perJm'y one of the following threc declarations: pLLROOR COVERINGS TO BE CLASS"A"OR BETTGR
i. i have and will maintain n Certificate of Consent m sel£-insure for WorkeNs
Compensation,as provided for by Section 3700 oC fhe Labor Code,for lhe
pe�formance of Ihe work for wliich this permi[is isaued, HAZARDOUS MATERIALS DISCLOSURE
s. I Uave and will maintnin Wockar's Con�pensatiou Ineucauce,as pmvided forby 1 heve rend[he hazardaus matm�inle raquircmcn[s undcr Chaptcr 695 oP the
Sec�ion 3700 of Ihe Lahor Code,Yor lhe perFormaucc oF Ihc work for whlch thie California HcaltL&Sulety Codq Scctione 25505,25533�and 25534. t rvill
pe��nit3s issued, m�iutaL�compliance with tl�e CnperH�io Mnnicipal Code,Chapter 9.12 aod the
s. i certiTy G�at in the perFocmanee of the worl<Poc whielt this pem�it is issued,I Aea1tL&,SaYety Code,Sectim�25532(a)shonld I store or hmidle haz�rdnus
shnll not e�nploy eny person lu any manner so as to become enbject to the material. Additioually,ahonld I use equipment or devices whicli emit hnznrdous
afr contnmi�mnts ns Aefined by tl�e Bny Area Air Qtmlify Manngement District I
Wockor's Compensation laws ofCalifornia. if,after making t6ie certiflcate of �vill mnintain campliance�vitL tlie Cnperfi�m Mm�icipal Code,Clmpter 912 nn�
exemptioii,I become snbject to the Workei's�Conlpensation provisious of the the}lealth&Snfety Code�Sectioue 25505�25533,and 25534.
� Labor Codq 1 must forthwith comply wi�h such provisions oi'this permit sliall � � /�r„�
6e Aeemed rewked. ����
Owner or authorized agent: s.� C_��� � �
APPLICAN'1'CER99F[CA'PION Oate:O6l11/2016
I certify[hat I have read this application and state ihat the above information is 11oNflTRT1c1TION i,ENDiNG AGCN(lv
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the pertormance
relating to 6uilding construction,and hereby authorize representatives of this city of work's forwhich this permit is issued(Sec.3097,Civ C.)
to enter upon[he above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless ihe City of Cupertino against liabilities,
judgments,cos�s,and expenses which may accrue against said Cily in Lender's Address
consequence of the granting of this permiL Additionally,the applicant understands
and will comply with all non-polnt source regulations per the Cupertino Municipal ARCHITF.Cl"S llLCLnRA'i'I(1N
Code,Section 9.78. I understand my plans shall be used as public records.
Licensed
Signature Date 05111/2016 professlonal
CONSTRUCT[ON PERMIT APFL[CA►fON
4 � CONIUUNITY DEVELOPMENT DEPARTMEN7� BUILDING DIVISION
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, 10300 TORRE AVENUE • CUPERTINO, CA 55014-3255 /_ �(� f�J
CiJPERTINO �408) 777-3228 • FAX(�08) 777-3333 • buildinqCa�cuoertino.orq ���p` "l OR- �
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By my si;nzR;e beloe�,I certify to each oS[he;ollowiae: I 2m the propeiTy owne[or aud�orii d zeeni to zct on[he�rope;ry o�y�ner's bel� lf. �hzve re2d this
appliceaon and che iefo:mstion I hz�•e provided is ror.ect I hz��e read the Description of 1�'ork and veri'ry it is zccuzie. I z�;ee to comply�eiU�zll zpoLczb!e Ixzl
ordinances znd stzte.lans relztin�to buildine conshvef . ��ut .ze reo�.sentztives of Cupe��ino to eater the zbove-identi5ed propeY,y io^r insyrection purposes.
Signzture of."-.pplicznUAgent: Date: LlJ
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0\ER T}'E COC\TER r LILDI\G PL�.\RE\SE\i
existine buildine(s). Demoli[ion pe�r„it is lequirzd ptier to issusnce of beildin $+ a z -� � >: �
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:or,n if any Haza�dow A4ztei�zls zrz be�i�Lsed zs n�rt ot"this pro,ect, � L�eE ' -: �eraF.nErr ,� �
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CopyofPlziL�ineAppiovalLetterorAGeene��s�:�liP�znviuep�iorto �,��z4J R - ;. ,j., ❑"s��rr�scE��ERni�7aici
subrni�al of Build;'.�e Pemiit zpplicatie;�. . �, - Y ; # :_ . r,'
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