06030064CITY OF CUPERTINOv
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iNFOt, ATION
BUILDING DIVISION PERMIT j
eG�®NTR�SLG�R
BUILDING ADDRESS:
APEX CI HEATING AND A/C
PERM""°'06030064
19550 STEVENS CRK BLV
ER'S NAME:
PERMIT ISSUE DATE
CONOCO PHILLIPS
1483 B
E:
SAN"ARY N0. CONTROL NO.
(800)622-7780
ARCHIIECf/ENGINEER:
BUILDING PERM" INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
I hereby arium that 1 ao licensed under provi cons of Chapter 9 hommaming
with session 7000) of Division 3 of the Businas and PrafaWOM Cade, Mai say license I-
smmlifonceanae
I. foll lance and i,e -4/476 zINSTALL
NEW CANOPY @ EXISTING FUELING STATION
o¢nw�lro co�uACNr
REPLACE ALL (E) SIGNAGE @ (E) FUELING STATIONS
DEC RATIO
Arecards IO
ORIG FILE/PLANS MISSING -THEY SUBMITTED NEW PLAN
shallhese
I understand my plans ahW he used as public
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby CrTum Not 1 am mempt from dx Contractors License Law for the
fallowing ranged. (Section 703 1.5, Business and Pro(easions Cade: Any city or County
which acquires a permit to consuuc6 shed Impsave, demolish, nr vapoir any slruclum
prior ha its iso uance. also mquires the applicant for such permit a file a signed statement
's Lice Law (Chapter 9
Sq. Ft. Floor Area
Valuation
Nat he u licensed pursuant to ax provisions of the Conmcturrvc
(commencing with Schon 7000) or Division 3 of the Basin. it Professions Code) -1
$30000
that he is exempt therefrom and the basis for Ne alleged eaempllon. Any violation of
Section 7031.5 by any applicant for a permit subjects de applicant to a Civil penalty of
ppN Number
Occupancy Type
not mart Nan five hundred dollars (950)).
❑ 1, as owner of the pmpeny, or my employee with wages as their sole eompeasaaon,
Required Inspections
nsrs
9 P
will da the work. and themudude is not Intended or offered for sale (Sec. IDH, Buaimas
and Prefaasimu Cade: The Con®cmLicense Lew dam out apply M an Owner of
property who bu ilds or ire prance thereon, and who does such work himself m through his
own employees, provided that such Impwwments arc not Intended oroRered forage. If.
however, Ne building or Improvement is sold within am yev of Completion. the owmr-
builder will have the burden of Ismaili ails that he did Out build or improve for purpose of
Mk.).
❑ 1. as awmr of the property, Mn exclusively wnuatorts with IlceneW Conuaeurs an
construct are project (Sec. 7006, Business and Pm(eadam Code:) The Contractors LI -
cease law does oat apply an M owner of property who builds or impmws theman, and,
who contracts rat such wakas with aeanlraclar(a) licensed paean to the Contractors
Dense law.
❑ 1 am anemP under Sec. . B & P C far this reason
Data
WORKER'S COMPENSATION DECLARATION
1 hcmby AfBne under parody of perjury am of the (allowing delantions:
rI 1 have and will maintain a CertiBete of Comcnt to calf -inure fa Workers Compen-
Mdan, as provided ran by Secuan 3700 of the Labor Code. for Ne performanR of the
were for which this pmnh is laced.
Q 1 have and will maintain Waskers Compenstaan Inwance, u raquired by Section
3700 of the labor Cade, fm Ne performance of the wave for which this permit Is Imcea.
My Workers Campeneaan In/urua�anier and polity number tic:
Cartier. 6J'%ITE /LWV Policy
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thu seam aed ml be Compimed if Ne 1-1111 froom hundmdda0an(SIM)
r
.,less.)
I cinify that in the p olormamc of the work for which this permit is issmd. I shall not
employ, any permit in any manneru as N become subject to ax Workers Compenadon
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. after making this Cenifica , of Exemption, you should
become subject in the Worker's Compenssdon provisions of the labor Code, you most
forthwith comply with such provide. ar this permit shall be dwmed devoted.
CONSTRUCTION LENDINOAOENCY
i
that Vert u lending agency O'er the Ixrfurmana of
I hor
s ed (Sec. 30
ora work for which Nb permit u issued (Sec. 3(197, Civ, C.)
which
Lenders Name
'
lander. Addrev
�
1 certify, that 1 have mad this application and sok that to above inrmmW un is
coned. I agree to comply with all city and county oMine.,$ and Mute laws relating to
building Convection. and hereby authorna repraemalives of Nis city to caner upon the
17 .hove -notal red pmpeny far inspecuun purposes.
L (Wo) agree to save, indemnify and keep haamleas the City of Cupertino against
liabilities,judgmcnn, costs and expenses which may in any way accrue again' Mid City
>• in conacescrae of to granting of this permit.
APPLICANT UNDERST Nos AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOU "n
Re -roofs
Typo ROOF
r am PPI anUConuacwr DataOf
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fuuuo building occupant start or handle haardom material
m deRncd by IIx Copertida Municipal Cade. Chapter 9.11. and the Health and Safety
Section 155314)?
All roofs shall be inspected prior to any roofing material being installed.
—/
❑Yes Nwe
If a roof is installed without first obtaining an inspection, I agree to remove
will The applicant at foram e equipmrnt or devices whim
building occupant us
emit hmssdom air cwumimnts as Jefood by ax Bay Area Air Quality Management
all new materials for inspection.
District?
0y.
I have seal the haaasdous maxriau mqulmmen l under Chi pter6.95 ofthe Didion.
nisIk lN& SafctyCode Sectiam 25505,15533 and25530. I undersand thaifNc building
doe ml currently hew 11 .3AL that It u my responsibility to Mary the, occupant orthe
require in et prior to issuance of a Ccnfxax of Occupancy.
Signature of Applicant Date
���—
All roof coverings to be Class "B" or better
owner en M606d Agent Data