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08030050 CITY OF CUPERTINO ra �.r' BUILDING DIVISION PERMIT yC© Y;ACTQR L �� .F,,........`.TsN BUILD)NAMESEv DE ANZA BLVD TBD TO BE DETERMINED P08030050 OWNEWSUNALME; J PERMIT ISSAS DATE CHEVRON PRODUCTS COMPANY 04/08/2008 PHONE SANITARY NO. CONTROL NO. 'TkCHITECTIENGINEER: - BUILDING PERMIT INFO BLDG ELECT PLUMB MECH Q � 0 �Op LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that lam licensed under pmvW ons of Chapter 9(commencing P with Smile.70W)of Division 3 afthe Business and Professions Code,and my license is NEW CLEAN AIR SEPARATR W/ENCLOSURE CENTRAL e F in full farce and erect. DM4 License Class Lim.N PETROLEUM PD FOR BUS LIC 3-11-8 9 Dam.Convector ee ARCHITECTS DECLARATION y 0 I undmuaml my plane shall W used as public recoals yQ Licensed Proportional OWNER-BUILDER DECLARATION <9 1 hemhy ol7irse that I am exempt from Ne Comractar's License law for the - E aO fallowing mason.(Section 703 1.5,Business and Pmfesdans Code:My city or county S$� which requires a permit to ennsuact.alum,improve,demolish,nr repair any structure iy prior to its issuance.atsU requires We applicant for such permit in Bk a signed naatement - < Nat he islleenseJpursuamtaNeprovismnsafthaCaevacuiaLecomLaw(Chupter9 Sq.Ft. Floor Area Valuation =Fg (commencing with Section 7000)of Division 3ofthe Business and ProfessionsCode)or S200o0 — that he u exempt therefrom and the basis fm the alleged eumptan.Any violation of Section 70313 by wry applicant for a permit subjects the applicant to•civil penally of 35908019P INumber Occupancy Type not romdame five hundred dollars(M). ❑I,u e.,ofthe ft suas,asmy employees with urgesrrndo(Se.compensation, wino the woes,Codec sum ontemnuas rLicodoraw doesed ntapSec.7044.asmor of Required Inspections as and erlywItaW Cade:The Conuuur'a License Law does not apply lf an owner of q P propertywobuilds aTimproves daemon,and who aressue twork himselfver through his awneer.me building or i pr such improto wit see not ear oftloroacma(or ate.if. however,thebuilding orimprovementissoldwithin oro ildofImproefortheowner- builder will have the burden of proving that he did wl Wim or improve for purpose of este.). h as owner of the property,am exclusively continuing with licensed contractors to mnswct the project(Sec 71144.Business and Professions Code:)TW Commuter's Li- cense Law does not apply in an owner of property who Wilds or improves thereon,and, who contracts for each projects with a aonummar(s)licensed pumusnl to the Contractor's Lie•..Law. _ ❑I are umap,under Sm ,B&P C for this mason Owner 9GS D.m WORKER 3 CPENSATIh�ON DECLARATION I hereby na an under penally of perjury one of the following declarations: l.have and will maintain a Cerafinu of Consent to self-iesum for Worker'sCamped- siru provided for by Section 3700 of the Labor Code,for the performance of the far which this permit is inaued. 0 I leve and will maintain Worker's Compensation Insurantt,u required by Section - 3700 of Ne labor Codc,for the Performance of are wok for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number am: Carrier. Policy NO.: CERTIFICATE OF EXEMPTION FROM WORKERS" COMPENSATION INSURANCE (Thu==.need not W eumplemd if the pcmA is fortune hunamddallars(5100) Or Ica) I codify the,in the Perfurrnaoe of the work for which this permit is Issued.1 shall as, employ anypersan in any manner u csubjecu the Wmilm'Compensation Lawearcarr r/a°�- �Aw Applicant / !j)•r — NOITCE TO AAPI WANT.If,after this Certificate of Exemption,you should become subject to the Wormer Compensation provisions of the labor Code.you muse 3 O foMwith comply with each provisions or Nu permit shall W dcemad revoked. ,z.�y CONSTRUCTION LENDING AGENCY [r I hemhy aRrm that More ie a construction lending agency for the Performance of ori► the work for which this Permit Is Wood(Sec.3097,Civ.C.) Q Lender's Name , z Lender's Address U e I modify that I have reed this application and s%in Nu the move information ie [I. comm.I agree he comply with all city and county callowness and name laws misting to building construction.and hereby aulhou repmsenwives of thin city 10 enIC"Pon the Lpl above-mentioned property for Inspection purposes. (We)agree to save,indconify and keep harmless the City of Cupertino against res liabilities.judgments,emu and cmemes which may in any way a..a get.,said City V z in consequence of the pending of this permit. ^t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE R^EGUTIOVP a Gc Re-roofs Signa a of AppliaMConua a Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant Or lot=Wilding acupentsue or handle huurdaus material as aeMcti by be Cupertino Municipal Cade.Chapter 9.12.and the Health and Safety COJe, E3y.25532(a)? ❑ ` 'o All roofs shall be inspected prior to any roofing material being installed. Yes `�N Will the applicant or future Wilding occupant use equipment ver devices which If a roof is installed without first obtaining an inspection,I agree to remove iL haxaaloes air contaminants dconcd by me Bay Area Air Quality Management all new materials for inspection. ❑Yns gNU I have mad the mordeor m`amrialsraquimmens underchapterti.95 ofthe Califor- ZniaHeslth&SafmyCede,Sections 25505,25533 and Z5534.1 undcmund hatifthe Wilding en not currently have a linen this it u my responsibility u notify the occupant of Nc mq name,which my} met prioryuann ccrulks =ancr. Signature of Applicant Date kA 7 0 roramhomnJegenl (� D,m' All roof coverings to be Class'W'or better