08030051 CITY OF CUPERTINO
BUILDING DIVISION PEPRAUTkCONTRA.CTQRI1I''�R ATIdl� .
BUI 1 G S: PERMIT NO.
�ESN DE ANZA BLVD TBD — TO BE DETERMINED 08030051
OWNER'S NAME: - PERMIT ISSUE DATE
CHEVRON USA INC 95700 04/08/2008
PHONE: SANITARY NO. CONTROL NO.
CHI'IECDPNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MI CH
fop LICENSED CONDUCTOR'S DECLARATION Job Description
1 III affirm Wt I am Iimesed under provriaa of CMPmr 9(commencing p
n� with Section7000)afDivinon3ofdm Buanes and Professor.Code,and my license u NEW CLEAN AIR SPRTR,NEW ISD SENSR@DISPENSRS
in full fame and effect.
e��'i LlcueClua Lic.R REPGRG
� mDam ARCHITECTS DECLARATION EXTNG TNK MONTRNG CONSOLE. CENTRAL PETROLEUM PD
y I undo Bund my plans Mall he used as public records
FOR BUS LIC 3/11/08
yQ Licensed Professional
Oat I ma exempt
fODECLARATION
CQ i I hcmhy e(Rrm o n 11. uempl from me Cosmos res License law for me
LOO which ng mown.(Salon 701.5.Business and w.da ope Code:Any city or seamy
9 which enquires a c.also to c res ft alar,hnpmsu demolish,fi repair any ummum
i!~^
poor aiuiensedprlsurs M the tieapplicant
,of for Comouch cmmt mifile
enssigned
aw(Cha mem -
Thoheiscing wit pursuant wthe of Dialoesof The CamrawsSLicenselaw,Codc)r9 Sq.Ft.Floor Area Valuation
r, Thai he Wexe pt Section t. 00)and
Division the
TheegBusiness uand Pe.An,AiCnM)or $30000
Seal io r exempt therefma and or aper far The subjects
me eampam.Any vluladm of
an,aSection man m any red doll for a permit anbjecu me applicant w a civil penalty of Number Occupancy Type
set mom Bun fin aunama dollen(550%. 31626096 :V2'
I,...arm.Property.or my employees eviN ergo.as their sola compnuatim.
will da Thewanal C dee The Cum auris License
i ens Law does
at apply TON,Budnes
and property
wh W Code:The Conueewr.and
who law ache Tat apply m tt awrcr or Required IDapechODS
properly wee guilds wl d out
suThereon,ane who me Out mac use himselred Wouah his
own emplayanI out such ire I,semenu pee set intended urneder.for gala If.
Wil w,me buildingwImpmvemantg aldwithinoneyesofmproefarmauwner-
MIIM will have The Wrden of PrONng out k did set breed w improve res puryose or
uJJle.l.
d1.as awrcr of the property am exclusively contracting aaim licensed mnuacan m
mnswn The project(Sec.70N.Baines and Pwfesse.Code:)The Contractor's U.
Oman law does not apply to an owner of Property who builaa or improves Netter,and
who contracts for such projects with a contradar(s)licensed pursuant in the Camnctor's
License law.
❑I am exempt undF See B k P C for This
Owner Dau —a vO
WORT S PENSATTON DECLARATION
I hereby sQirm Mer penalty of perjury aro Or the following declarations:
IL 1 ham and will mndomm a Certificate afC..rt to self-moues fes Workers Compete
W
,a provided fes by Section 3]00 of the labor Code.I.me perform.of me
far which Thr permit is issued
❑1 have and will maintain Worker's Compensation Inu mute,as required by Section
3700 of The labor Coae.for The performance of the wark for which this permit Is issued.
My Worime.Compensation Insurance carrier and Policy number am:
Carrier. Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ThraeNm need not Im completed If the Permit is forone hundred dollars(SIM)
or less)
1 cutiry met in ate performance or the work fes which This permit r lance,I Nail rat
cmplcyany pecan in anymanrcrwu M m bjtetwme Warkesi Compenatian
Laws of r1hranr.Damo ,
Applicant O rY-4_ - U_
NOTICE TO PWGNT:IL slid ffiakfing this Certificate of Exemption,you around
Obmhwi ono y the Worker's Compenr this a provisions of me Lahr Coda you meet
forthwith comply with each provisions or ser permit shall ere deemed revoked. ,
Z M CONSTRUCTION LENDING AGENCY
[r► IMmby Affirm that mere it a mnsmmtinn lending agency for the lerforexame,of
LY. The work for which Thr Permit Is issued(Sac.3097,Civ.C.)
aR Undoes Num ,
.7. z Undoes AMmss .
U O I comfy that 1 have rend this application and sum mu the show Information is
TL ^ cortaw.I agree TO comply with all city rod county ardinanms and rum laws rotating To
Q SV' building construction,and Thereby mmarim mpoommaives of this city to enter upon The
Gil .hove-man mom!property for impaction ra rpoma
LL (We)agree to an,indemnify and lamp hutnmas the City of Cupertino agaipet _
rr fA imbiliBaa julgroeas,case and expenses which may In any way&cc=agaWl sold City
in consequence of the goafing of U APPLICANT UNDERSTANDS AIND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIO S! / /
Alia 0 a9 Gr,r JOU404 e, 41- 1-6$ Re-roofs
STMT of Appli=nUC r Data
HAZARDOUS MATERIAIS DISCLOSURE Type of Roof
Will The applicant or run=Wilding ocwrPeratme Or handle haalloes material
as III by BO,Cupenim Municipal Code.Chapter 9.13.and our Health and Safety
Cade.Section zsr3a(a)] �// All roofs shall be inspected prior to any roofing material being installed.
❑Ya ` 6. ,
Will The applicant or future building occupant use equipment or dormers which If a roof is installed without first obtaining an inspection,I agree to remove
It haardaas air contentment,as dcOmd by the Bey Area Air Quality Management all new materials for inspection.
Wal 1 //
❑Yes RINu
I Msc rend the heallom77TTTT"mamridrmquimmewwderCMpmr6.95 afore Ulifw-
au k4l"Safny Coda Seeaons255W.}.5533ped35534.1urderaandTh g&Wilding
deer Out comendy Mw wn .Kmart
a art.seIt is my responsibility m really ere Of the
reqwmmentr which a=W=IpnarmmuanmaraCwrrteama4"F.'. SignatureofApplicant Date
All roof coverings to be Class'W'or better
Ow ror mthoms0 agent Dam ail