06020074CITY OF CUPERTINO
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BUILDING DIVISION PERMIT.
N„TRACTQR3INFORMATION'""'
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BUILDING ADDRESS:
PACIFIC GENERAL CONSTRUCTI
f6MITNo06020074
19634 STEVENS CRK BLVD
OWNER'S NAME:
PERMIT ISSUE DATE
dh POTSTICKER KING
43050 CHRISTY ST
03/02/2006
aE:
SANITARY NO. CONTROL NO.
(510)824-0490
ARCHITEC (ENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 rarity from Nn 1 am licensed under pmvisions of Chapter 9 (Commencing
P
with Section 7") of Division 3 of the Business and Profcuions Codc. and my license is
In full forte and effect
REVISION -2 ROOFTOP MECHANICAL PLATFORMS
LiaClass o
Datem CContrnteactor
NO NEW PERMIT ISSUED/ORIG. #05010010
ARCHITECTS DECLARATION
I understand my plans shall be used as public meet&
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm Nat 1 em exempt from tW Contractor's License Law for the
rollowing on. (Section 7031.5. Business end Professions Cole: Any city or county
which requires a permit on consumer. eller. Wprow, demolish, at repair any structure
prior to its issuance, also requires the applicant for such Permit to File a signed staemenr
that he u licensed pursuant to the prevision of tW Contractor's U.. Law (Chapter 9
Sq. Ft. Floor Area
Valuation 0
(commencing with Section 7000) of Division 3 of the Business and Prbfmsimns Code) or
Net he is exempt therefrom and the basis fur the ailcged exemption. My violation of
APN Number
ane T
Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not mom than five hundred dollars(s5 L
369060009.00,
vP y
❑ I.uownuofthepmpwy,mmyemploymwithwaguuft4mkc M=don,
will do the work, and theswmum is not Wended or offered for sale (Sec. 7014. Business
and Pmfnsions Code: The Commoner Lim. law dm not apply to an owner of
Required Inspections
property who bu ilds or improm thereon, and who does sue h work himself or through his
own employes, provided Nat well improvements sum not intended or offered for sake If.
however, the building or improvement is amid within one year of completion, the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of
tale ).
1, u owrcr of the property am eachri ively contrmsing with licensed contractors w
C nstruct the project (Sec. 7044, Business and Professions Codec:) The Contracur s Lb
comm taw dm not apply in an owner of proyenywW Wilds or improves memon. and
who contracts for su5h projeeu with a contvmor(s) licensed parallel in the Contswtnri
License Law.
❑lam escrept der See. this iso
1,B&PCT
t
Owner (
//A Da
WOR C O P SA b RATIO
I hemby affirm under penalty of perjury one of the following declanuom:
Q 1 have and will maintain a Certificate of Consent to self insum for Workeri Compen-
anion, at provided for by Section 3700 of due labor Code, for the pceformanm of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation I.., as required by Section
3700 at Lmor Code, for me performance of the wok for which this permit is leaned.
My Workers Compensation Inwnree carries and Policy number am:
Cartier: Policy No,
CERTIFICATE OF EAEMPTON FROM WORKERS'
COMPENSATION INSURANCE
(Thu sombre need not W cumplced lithe permit U forone hundreddollan(3100)
or lass)
1 oenify matin the performanec pf the work fpr wKeh oris permit u issuedI sh
. ell Out
employ any person in any manner b e j. t to dm.Wmr1m. Con Mother
of California. Dam
Applicant
NOTICE TO APPUC/t g 0 e dears o Excm ton, y out
become subject m the 0 Compensation pmvisions of me labor Code, you must
forthwith comply with well pmvisions or this permit sball W deemed minted.
CONSTRUCTION LENDING AGENCY
I hereby affirm mal them is a construction lending agency for the perfurmmce of
the work for which this permit is issued (Sec. 3097, Civ, C.)
Lemon's Name
Lender's Address
1 certify that I have mad this application aM sum that the sWw infonnafiun is
COMM I agree to comply wit all city and county ordinances and sure laws misting re
Wilding construction, and Wreby euthmrim representatives of Nis city m enter upon the
above-mentioned property for impection purposes
(We) agree In cave, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, Costs and cape=, which may in any way ane against said City
am
in comequenc, of the granting of mil Noon.
APPLICANT,UNDERSTANDS AND WILL COMPLY WITH ALL N N -POINT
Issued by: Date
SOURCER UADNS��"./�
—
Re -roofs
am Ap���
nc I� Olue
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant Or future building acupant stem or handle hen ckno, meedei
u derided by the Culmina Municipal Code. Chapter 9.13. and the Health and Safay
Cade. Section 355320)?
❑Yoe pNe
All roofs shall be inspected nor to an roofing material beim
P P� Y 8 g installed.
Will the applicant or future Wilding oecupant use equipment sur dcvim which
If a roof is installed without first obtaining an inspection, I agree to remove
nnit haurdous air cmntaminams u deOnctl by the Bay Area Air Quality Management
all new materials for inspection.
Diemen
❑Yes No
I have mW the hamoders materials mquiremcros untIMCheper A95 of the Califor.
.is Health& SafetyCude, Sections 25505.25533 and 25534.1 undetamrd that ifthe Wilding
data am c lly haw a mann, that it is my responsibility in oni fy me occunt paof the
'
requiremen whichmusretpnorW fa enifcae mf Oce c
Signature of Applicant Date
oAt�n � � ��
roof coverings to be Class "B" or better
son rammnrtacdegent Dm,All