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02060028not t u� j �Z' z t N - O w vai3a� ao_t :C4 e aims _�zz_zr at a 1 l z z° aQ Z;) Z U O OU }kl uz I CITY Signature of Applicant Date -:. All roof coverings to be Class eB” or better - Owner' ranmai,ee a , ,e y, CITY OF CUPERTINO ' BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: - BUILDING ADDRESS: PERMIT NO 19030 STEVENS CREEK 02060028 WNER'S NAME: APPLICATION SUB DATE ROBINSON OIL 06/05/2002 'PHONE: SANTTARY NO. CONTROL NO. AR CHITECDENGINEER: - BUILDING PERMIT INFO BLDG ELECT PLUMB MECH C =7 LJ L"J I -J '. : LICENSED CONTRACTOR'S DECLARATION Job Description 1 he eby Reim ih t 1 m I en. d u d nx of Chapter 9 (cummmcing' wkh Semmn]000i ofD n 3 o th Bht s aPrdreeeibaa eade.,na my license PIJMP /DISPENSER /SUB PANEL is in r IIR ,tm� ndyy'feet a >1 LiEen ItJSR.. GrN .. I. �) ': �' Ic•:T Q t��"i..w ..Cum' cto .. .. . Jr/ ARCH ECTt DE A N ✓ 1 ut�lflstand m �' be sake es punli 'eards LiL�,'Pruffsiioa• — OWNER-BUILDER D RATION I hereby affirm that 1 am exempt from the Contractor's License law for the following reason. (Section 7831.5. Business and Professions Cade: Any city or county' $15000 wren ic,ircoa permit to ornsence, niter, improve, demolish, or repair any structure „Prior torts issuance,also"iflueaaheapplkam forouch permit m Blensignd smumem - - mae huts licensed pursuant to the provisions of the Contractors License Law (Chapter 9 F' r �,..�. Valuation (enmmenein with 'Sectian,70R0) of Division 3 oldie Business and prof ssians Code) I; fe'F�. � • ' •. I - e.. f or that tic is 31.5 by any applicant li and the avers for the alleged exempdoo Any violation of Section ]031:5 by any vpplicvn( for a permit subjecu the applicant to s civil penalty p7UrDj3�(� .of nor more rasa five hundred dollars (SSW). 304APN 12V L1till ELECTRICAL °,: r ,, Occupancy Type O 1. as owner of the property. or my employees with wages as their sole compcnsmionAL ENERGY - wilPdame' work.' andthestndurc' ianotinrcndcd 'arnrfered- rareale(sec.]aa." - - - -- 505 — FINAL EIifl °JR2��°AFlei 'Business and Professions Code: The Contractor's License Law does not apply to an CIlOHS' ... of property Who builds or improves thereon, and who d «s such work himself or through his own employees. budded that such improvements arc not intended or ;offered I., .1c. IL however, me building or tmprovcmrnt is SoIJ within one'YeSr of "" "' ' ' _. ....._ . ......... .. .....__._ ..... ...... .._ _.._. .. ... _ _. 'coopletion, the owner-Wilder will have the burden of proving that he did not Wild or ' improve for purpnse of sale.). ._ -_ _._.. .._.... _._,....___. _,..--- -_.... ___._. I'm- ... .. _..._.._ _.- . _... ... _. _.. .... .. _._ ..__. ._.._____...,.. .__ _ -.......... _........_..... co n as owner pr the p(Sec. 7 am Business a d Professions wire de:) Thcontractors to .. . cnnsVUCt the project (Sec. ]06x, Bus and ProPoex s Cale;) The Commctor's License law does not apply tole owner with. a, conty wno) Initiated at improves thereon, -and whD.eontmeu for such,Drojeety with.a.commnortA IieeasW Pursuant.m.ehe .. -. _.. _._ _._ -.. .... __ __... -. .._ _...__..... __ ...___..__ ....... -:.._ _....... .._._. _...___.__._._ .. Gone... eon p«nu L ❑ 1 em a pi order S � _ " _ , B @ P C for this rcusun ] '. �e,A p�• �,• •�w O !.Y t f,;1WORKER SCOMPENSATION DECLARATION - r AUG lie I hereby arfrtm rider pc Ity.of pea ry ne fithe following declarations: 1(1119 ❑ 1 have and'wdl m rt n . Ceri finale f Consent io salt nsure, for Worker's VV CC Compensation as provided r by Sect 3]00 of the labor Cade for the BU IL �JPerformance of the wo k f h h this pc t .. tied: r U O l have and will 'mdinmin Workers Compcnsoumth at m iCe, as required by Sciaiom 37W of the Labor Code. foe the performance of the work for which this permit is ssoed My W k s C pe e 1 survnc /e comer anJ Pol cy'numbcr are ' r�4L{@b 'D.,tiatdl +No laAors-�. -.__.. .... ...__..____......_ .:•......,. �.., t,., �. ......,....,W..- _.....__,,..... ' , 'CI•RrIFlCATION.OFL PTIDN FROh1 WQHKERS' !, III' t.fl' }1'.. t�V�,•t .�.• }•�s') \s `�•' l'"'' '- ` "COMPENSATION INSURANCE' I' � ' " t tart c'a'me section' need not he eontplered if the permit is for one hundred dollars `' ISI00)or less) 1 Certify that in flit performance " f the k f which this pc t'. issued, shall a employ any person - in any manner s to became ubjcce to the Workers Compcnorno." Laws of California: Dale ' r.: Applicant.. .,. .. ..._ .. _ _ .. ..._ ._. .. ....._ .. ._ _...: _..._ __..__.. . NOTICE TO APPLICANT Ir after making this Certificate of Exemption: you should f - hecbm2suhjecuo the WorkersCompensoms provisions ofeaeLuWr Code. you use forthwith Comply with such provisions or this penninhall be deemed revoked. m CONSTRUC, TION LENDING AGENCY' " t ' 1 herchy affirm the there is a cd s nctmn lending agency for the performance of maw6rk fm which this permit is issued (See. 309]. Cite C.) , LealeN ... . - _.. ... .. _. _... .. .. ... _._ .. .. ... _. _ _ .. .... _. _.. LEnd Addr , ✓ 1'c n fy ih t I li d th application d state that the above information s [dtmelugrceh'cply eh ll city aid tygd n dtt law, eltng' io bu Id rig, tucirurlaadhreb) archona reptcsenuues ofihs city to enter upon ,he•aLvcmemrnned propcny for inspection purposes.' (We) hl 1. Dave, indemnify'ond keep harmless she City'i,f Cupertino ugaina liabilities, jud8ments. Costs and expenses which,may in any way accrue against void City n c scquen« of the gray n8 urthi pc t •' - ' re xAyucj�NTUNOBRST4 f \ND WILI COMPLY I\'ITH S 6N- POINt' ISSUed b 'r Date mil/ 'OUR�� GULAT._' aJ •B� y Signs n„ P pis n u nr T Dae �,; Re -roofs / ALARDOU, RIMS DISCLOSURE :. ,' Y pinlno M1l 4P.I p'v atom a.harml n aNwsm e<'1 T e'of Roof -. •._.._._. ... ,.•..._...... r•..._., „ . ...... .. ...... . .•. W II me ppl cant f N 6i Idin asdrnedb theC Chapter 9.12. and the Health and Safety yp ,t e, 4 ( , Coder�cYes 2553 Itntt 'aFN . t Iql ' All rOOfs Shall be Ins e' C y. _ r p cted,prior to any roofing, material being.mstalleti. W ll the upplic t vut n ild�ag p tope eqn p e e ,CC, which If a roof is installed 'without first obtaining an inspection; I agree to remove em t hazaNO.s air. eemann n nr ns define by the Bay Area A r Qdal ty Management District? . `.`. all new materials for inspection. Applicant understands and will comply with. ❑Yea „` . Not .. .:.. .., . all'non =point source regullattbns. 'tit '.I. have «aQthe'hvzardlous `mareni k requiumcnts under Chapter 6,45'a . I the Califoioia Health @ Safety Code, Sections 25505, 25533 and 25536. 1 Coder tnnit in t r me M�ildingit sna currently veaunant.that"'a my.apons,1,1ny m notify the - 'accup5nt of e t quip menu w h met o, met, prlor,m issuance of a Certifi«te of 'y t. ... OFFICE- _ _. ... _ ..... ..- .. . Dtt CUPEQNNO CITY OF 1C 1GRME 1L L-111C 1C L1LCA Jl EO F®1LVM APN # Fee RD Date: ]Fee Group —Quantity APTFEE EACH STORY OVER 3 Building Address: HOTELFEE EACH STORY OVER 3 ?6_40 S *6 c OFFICEFEE Owner's Name: Phone M BAPPLOTHER /Mxom ©�` MECHANICAL 2.s'2 r i % Z 0 Contractor, BUILDING License M BCONSTAX a BUILDING BCONSTAXBQ Contact: BUILDING Phone #: BCONSTAXH l gq re -Ak'r> BUILDING BCONSTAXR Applicant/C ntr�tor: BUILDING Fax #: BELEC1000 Elec 600V <= 1000A. ELECTRICAL BELEC1001 ilding Permit Info: ELECTRICAL B1 L 2 0 401 r_ 2, lect lum Mech Jo escription• < I�ENERGZY Residential: `°' C erci' Sq.Ft. Floor Ar. Energy Add Multi $ Sq.Ft.:.'� ArchitectlEngi eer: Investigation fee Valuati n: Type of Construction: Comm. Housing Mt. Fee Occupancy o p: °1 1 of 3 Fee RD Fee IlDesc>rn tioa ]Fee Group —Quantity APTFEE EACH STORY OVER 3 HOTELFEE EACH STORY OVER 3 OFFICEFEE EACH STORY OVER 3 BAPPLOTHER Other Appliances MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX In(VOWConuiVlQuasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax – Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A. ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL I�ENERGZY Energy RUILIDIN G BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mt. Fee BUILDING BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi-Family Res MECHANICAL BNEWMULTI New Multi - family Res ELECTRICAL 1 of 3 ry OF CUPERTI NO BUILDING DIVISION P�'j IT BUILDING ADDRESS: 19030 STEVENS CREEK OWNER'S NAME: ROBINSON OIL PHONE: u O O ARCHITECT/ENGINEER: �U ¢z N ¢ N N Z LICENSED CONTRACTOR'S DECLARATION i Z 1 hereby affirm that 1 am licensed under rovisions of Chapter 9 (commencing ` F w with Spelion 7000) of Division 3 of the Bi si es and Professions Code, and my license ,, isinfull!taudpt'rt.® 1 L se ,y� �„ I z VJ O a V ai ��st n",Jt'n�,,' Cont act F l� e 1 " O h ARCH CTjs DEC N 0 .aa understand %m be u1cd as public records i�Y�� C'�J� _ i _ p O License Pro sional jc o F� OWNER - BUILDER D ARATION ur — rn I hereby affirm that I am exempt from the Contractor's License Law for the F Z ¢ following reason. (Section 7031.5. Business and Professions Code: Any city or county' F2 p which requires a permit to construct, alter, improve, demolish, or repair any structure ce m — m prior to its issuance, also.mquires the applicant for such permit to file a signed statement d 3 — that fie is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing ,with Seetion.7000) of Division 3 of the Business and Professions Code) or that he is exempf therefrom and the basis for the alleged ejremptioli. Any violation -of Section 7031.5 by any applicant for a permit subjects the applicant to anvil penalty, of not more than Bye hundred dollars ($500). ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do-ilie wo& and the structure is not intended or nffered for sale (See. 7044, 'Business and Professions Code: The Contractor's License Law does not apply to an owner of 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 pffered foi sale- If,'however, the building or improvement is sold within one'year of corripletion, the owner - builder will have the burden of proving that he did not build or improve for purpose of sale.). d 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 License Law does not apply to an owner of property who builds or improves thereon, and.whp- contracts for such projects.with.a contractor(s) licensed pursuant to the Contractor's License law. ❑ I am exempt under Sec: f , B & P C for this reason OwrK'r - Date WOKERiS COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, 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 carrier and Policy number are: er. '10.4 4 c`63' i No.: _ CEPTIFICATIONAF,EI6,, 0M WtKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued,' 1 shall not employ any person in any manner so m to become subject to the Workers' Compensation Laws of California'. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption; you should ®®become subject to the Workers Compensation provisions of the Labor Code, you most forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY' ' (,hereby affirm that there is a construction lending agency for the performance b of the work for which this permit is issued (Sec. 3097, Civ. C.) Q Ldnder's Name �-� UpidefSAddress ® 1 certify that I have read this application and state that the above information is �+ � cdrrfci. I agree tp.c .. ly, with all city and county ordinances and state laws relating ®'. to b6itdirig sirv'cti�'arrd hem1ly authoriza *represematives of1his city to enter upon yy W the�above -men ioned property for inspection purposes. �. A (We) agree to save, ihdemnify and keep harmless the City of Cupertino against ra V1' liabilities, judgments, costs and expenses which may in any way accrue against said U 4 City in consequence of thl; gm ing of this permjL ' p 1PPLICANT UNDERS 4. A.ND WILL COMPLY WITH A L NON -POINT OURC GULA Sign plie o or Date d� rAZARDOUS RI'ALS DISCLOSURE - Will the applicant or future but ding occupant store or handle hazardous material as defined by the Cupenipo Munlpiptil Code. Chapter 9.12, and the Health and Safety Code:'Section 25532(a)? ❑Yes. ' No' , Will the applicant or future building occupant use equipment or devices which emit hitArdous air conm unans as defined by the Bay Area Air Quality Management District? ❑ Yes XNo • I have read the havardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the building do notcurten 1, ve a tenant, that h is my responsibility to notify the occupant of quiremenes w h con stbee met tpprior to issuance of a Certificate of PERMIT NO. 02060028 APPLICATION SUB DATE 06/05/2002 SANITARY NO. CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB MECH L 3 L_1 L- -7 1 _ .1 Job Description PUMP /DISPENSER /SUB -PANEL $15000 3 7�1F 'CI17_�Z,��nnr11, - :, . ',1 304 APN RU it ELECTRICAL 50i FINAL -ELEG-TRIGAL BNER 505 - FINAL EA§ltbA:nctions Issued by: r Date Re -roofs Type of Roof All roofs shall be inspected prior to any roofing material.being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Applicant understands and will comply with all non -point source regulations. Signature of Applicant Date All roof coverings to be Class "B" or better OFFICE