07110050CITY OF CUPERTINO
BUILDING DIVISION PERMN
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BUILD I D FSS:
Tb�3 N WOLFE RD #2074
TBD - TO BE DETERMINED
PERMIT NO.
07110050
OWNER'S NAME: '
-
PERMIT ISSUE DATE
BENIHANA INC
02/27 2008
PHONE:
SANITARY NO. CONTROL NO.
ARCHTTEC (ENGINEER:
BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
I hereby affirm lbat I am licensed under provisions of Chapter 9 (cummcocing
-
with Section 7000) of Division 3 of the Business and Professions Code. and my Been= is
T. I • REMODEL OF EXISTING FULL SERVICE RESTAURANT
in full force and effect -Z/ / _ 3 iq !
License Class Lic. p - % "-
E / M / P
Date 2%, Contractor a 14 Y coms
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following ,coon. (Section 7031-5, Business and Professions Code: Any city or county
which requires a permit to construct. alter, improve, demolLch, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
he is licensed to the of the Contractors License Law (Chiptcr 9
Sq Ft. Floor Area
Valuation
that pursuant provisions
(commencing with Section 70D0) of Division 3 of the Business and ProfcCode) or
.
$sslons 2 2 5 0 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
2 A�Tr
e
Occupancy Type
J
Section 7031-5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (ssDD).
316 010 0
❑ L as owner of the property, or my employees with wages as their sole compensation,
e ns
Required Inspections
will do the work. and the structure is not intended or offered for Wc. (Sec. 7044. Business
and Professions Code The Contractores s I ken Law donot apply to an owner of
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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.).
.
❑ L as owner of the property, am exclusively contracting with licensed cura actors to
constr= the project (Sec. 7044. Business and Professions Code:) The Coarraaors Li-
cense Law does not apply to an owner of property who builds or improves mercon, and.
who contracts for such projects with a contractor(s) Licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec , B & P C for this reason
Owner Dale
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WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declarations
❑ i have and will maintain a Certificate of Consent to self -insure for Workers Compere
'
radon, as provided for by Section 3700 of the Labor Code, for the performance of the
wort for which this permit is issued.
❑ i have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the wort for which this permit is issued
My Workers tsation Insurance caricr,xid $o�o numbberrF13 am:
aa��Compe
Carrier. /^rr� t �a 4i Pofiey`No.-.01i 56 O S Fi 9VG
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed it the permit is for one hundred dollars ($100)
or Icsa)
I certify that m the performance of the work for which this permit is issued. I shag not
employ any person in any manner so as to become abject to the Workers' Compensation
Laves of California. Date
Applicant
NOTICE TO APPLICANT: If. alter making this Certiftcare of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this Permit shall be deemed revoked.
..
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Name
,
Lenders Address
1 testify that I have read this application and state that the above information is
Correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit
APPLICANT UNDER DS A�'j� WILL COMPLY WITH ALL NON -POINT
Issued by: Date Z -- 27� C4�,
SOU E R ULATIO
Ug
Re -roofs
ature of ApplicanUContractor art
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, scares 25532(a)? -
All roofs shall be inspected to any roofing material being installed.
❑Yes 'PNo
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District? _
❑ Yes [� No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant tha 't is my responsibility to notify the occupant of the
re ire ntswhc ometpr w;ssnanae
Signature of Applicant Date
afaCertificateOfOccupanry.
/277 DR
All roof coverings to be Class "B" or better
/Date
wncr or authorized agent