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CITY OF CUPERTINO'
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13UILDING DIVISION PERMIT
CONTRACT0R4NF0RMATI0N ,
ADDRESS:
PACIFIC GENERAL CONSTRUCT
fITVITNO 06010029
FBUILDING
19780 STEVENS CRK
WNER'S NAME:
PERMIT ISSUE DATE
EVERSHINE VI, L.P.
43050 CHRISTY ST
02/24/2006
ONE:
SANITARY NO. CONTROL NO.
(510)824-0490
ARCHITECIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O O
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 strum that I am licensed under Provisions of Chapter 9 (commencing
i
with Section 7g1U) ofDivision 3 of Ne Business and Professions Codc, end my license is
ion 7
in fullfnrmandefreat.
TI --ROOFTOP ODOR FILTRATION SYSTEM
License class Lk.a
Date Centimeter
TO (E) EXHAUST HOOD
ARCHITECTSS DECLARATION ARATION
'
I uMerstanJ my plans shall be used as public records
Licensed Psufessional
OWNER -BUILDER DECLARATION
I botchy affirm Nal 1 tum exempt from de Contractor's Licarc Law for the
following moan. (Section 703 1.3, Business and Professions Code: Any city or coumy
which requires a permit m construct. alcor, improve. demolish, or repair any strucue
prior m its issuance. also mqui= plc appli.m for such permit to file a signed statement
Met he is licensed pursuant to Oe provisions of Ne Contmaor s License law (Chapter 9
Sq. Ft. Floor Area
Valu Eu0 0 0 0
(commencing wide Section 7010) of Division 3 of dee Business and professions Coale) at
that M is; exempt Nciefrom and Ne basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects to applicant to a civil penalty of
Nan five hundred dollars
APN Number
Occupancy Type
p y yp
bemore (55001
3 6 9 0 6 0 0 8. 00
❑ 1, u owner of Ne property. or my employ,. wide wages u Neil sol. compme aOon,
will do Ne work and Ne swcnum is non intended at offered for talk (Sec. 7044. Business
and Professions code: The Connector's License Law dors not apply be an owner of
Required Inspections
proseny who builds ar improves Nercon. and who does such work himul f or Ouough his
own employees, provided Out such improvements art nminen&d or offered fursale. If.
b Ne building or improvement is sold within one yyearof completion. Ne owner-
W
builderilder wiB have dee Wellen of proving Nan he did Out Wild or improve for puryoa of
ata[1cJ.
�l 1, u owmer of Ne pror, peam exclusively contracting with liaised Contractors to
Buct Ne project (Sec. 7W, Business and Professions Code:) The Comraaor's U
ccve law daes not apply us an owner of property who Wilds or improves desmon. and
who LaGLL for such pmjcCLS with a ceplraclef(3) Ilab N
Med pursuant e eantraClOr!
License Law.
0Irenvm.cmpt under Sec.t ,B&PCfmr this mason
�
/�/ X� Date d
WORK RS COMPENSATION DECLARATION
��
1 hereby arm under penalty of perjury one of the following declarations:
❑ I have and will maintain a CeniOCo¢ol Covent to self-insumforWoM1cr'sCompen-
adon, as provided for by Section 37M of the Labor Code, for Ne perfermma of the
work for which this permit is issued
.
O I have ad will maintain Work.! 3 GompeNation IRWMa, as Rgalmd by Section
3700 of Ne Labor Code, for Ne perfmcbma , of Ne Work for whim Out permit is issued.
My Worker's Compensation Insurance xrtkr and Policy number am:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nesse0don need non W completed if dee permit is fmonc hundred dollars ($100)
or less)
I ceNfy Net in Ne perfurtm nee of Ne work for which Nis permit is issued, I shall out
employ any person in my manrtr✓s az o c, l�bjecuo NC WorI 'Compemalm
Laws of Caiflomia. Date (1
Applicant of
NOTICE TO APPLICANT: If, turner making this Ceni tem of Exemption, you should
biome subject m Ne Work.'s Compensation provisions of the ISWr Codc, you most
fonhwide comply with such provisions or deis permit Shall W lamed revoked.
CONSTRUCTION LENDING AGENCY
I hemhy affirm Nat Nem is a construction lending agency for the perfurmanc. of
Ne wart for which this permit u issued (Sec. 3187, Civ. C.)
tender's Nam.
Lcndch Address
I certify Nat I have read this application end sate Man Me above information is
cmmm I agree to comply with all city and county ordinances and state laws relating w
building consouaion, and hereby amhorim toPresenutiver of Nis city to enter upon the
above mentioned property for inspection purpngi
(We) agree to uve, indemnify and kip harmless the City or Cupenino against
liabilities. judgments, costs and expenses which may in any way accrue against said City
in emnequcnee of Ne granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCEU
Issued by: Date '2— Z L+,
i�z�
Stgnaturc(Appir Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or Tums¢ building Occupant slope or handle harudous material
M &Med by tie Cupenino Municipal Code. Quarter 9.12, aM Ne HcaIN and Safety
Cole, Section 25532(.)?
❑Yes )(No
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or Norm building Occupant tree cyuipmCot or devices which
If a roof is installed without first obtaining an agree to remove inspection, I
P
Cult havacdmer air contaminants o Defined by the Bay Ams Air Quality Mavgcmenn
DistricR
all new materials for inspection. -
0Y. 'u
1 have read Ne hilarNms maurialsmyviremcnts under Chapterb.95of the Cubic,
.j.HcalNS:Sde,Co&, Sections 25505.25533aru125534. 1 mucen alOut if Oe Wilem,
does but Currently have a WMML that it i3 my responsibility m ably Me dmV,ml Of Oe
mquirtmcnu ich/must eomet prior In issuance of acemiMawor«x/pe�n,fay./y
Signature of Applicant Date
//// �K G' ✓2/ ^ //f.b
All roof coverings to be Class "B" or better
Own er dr authorized agent Date