05090134 CITY OF CUPEPERMIT CONTRACTOR INFORMATION '
BUILDING DIVISIONSION
BUILDING ADDRESS: PERMIT NO-05090134
R'S NAME: PERM T ISSUE DATE
SHELL PRODUCTS CO. 12/22/2005
�" EP ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�0' LICENSED CONyRACTOR'S DECLARATION Job D0SCr1 hOn
uF 1 W reby affirm Nat 1 am licensde
ed under provisions of Chapter 9(eommoloin, (f l p
Zl t� withSection7")ofDivision3 of the Business and Professions Code.and my licenx is A #
<��
in full(one and effect �as3-70Z) TI-NEW TANK/PIPING/DISPENS'ER./E�.VIC
Z Licenx Clus Lic.0 -1 a �.y
egg Date Conuactor_Y.E e- 0.2-1 !'fa
'rS 7W R Hf1EC1'SDECIA ATION
W I understand my plans shall W used as public mends
le Licensed Professional
Oat I am exempt
from
m CLARAT ON
oto
E 00 I hereby.(firm Net I I.S.exempt from Ne Cemmus Co Licenx Law for the
E
p O following moon.(Section 7113 stnBusiness and eve,de lou Code:Any city as county �a
K$ which requires a permit m ennsma,alter,improve,demolish,or repair any nmpure 2 O O O O O
VZy prier to its issuance,also requires the applicant for such permit to rile a signed sl]Nmenl
ESC NoW m licensed purmanstothe pmvisiont ofthe Convacter's License,law(Chapmr9 Sq.FL Floor Area lua[ion
Xa (commencing with Sotion7(X00)pf Division Sof NC BusirlovaW Pmfessiou Cndc)uf
y2§ Nn he u exempt therefrom and the bum for IW alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of P O
not more than five hundred dollars(S5W0 Occupancy y Type
❑I.u owner of sfie pmp ray,or my employcu with wage u dch xle compenudon,
willdo IWwortand NeswnumisnosinmMdoro@reAforsane(Sec.7w.Bue ..
and Professions Code:The Contractor's License law does not apply W an owner of Required Inspections
property who builds.(.proves thereon,and who doessuch work Houseful though his
own employces,provided Nat such improvements are not intended woffered fosale IL
however,the building or improvement is mid within one you of completion.lie owo s-
builder will have she burden of proving Out W did not build or improve for purpose of
sale).
❑1,as owner of the progeny,am caclusively convecting with licensed comescmrs to
construct IW project(Sec.7044,Business and Prefectures Cade:)The CovxWr's U.
come law does not pply he an owner of propeny,wW Wilds or improves Neuron,and
who contracts for such pmieos with acommeor(s)licensed pursuant to On Contractor's
License Law.
❑l am exempt under S.C. ,B&PC for this mamn
Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the following declarations:
Iha`CandwillmalmainaCenlrieaxof Conlon NYlf-insumfWWo {,Compere
sation,as provided for by Section 3700 of Ne Labor Cade,for the Performance of the
work for which this Permit is issued.
❑1 have and will maintain Wwker's Compensation Imuran,as required by Section
3700 of the laWrCols,for Oc performance.(lW work for which Nis permit is issued. -
My Worker's Compensation Insuran arrier and Polity number am:
Cartitr:6n0 �"[i.../1 Policy No.:/�"1,- o IY'7t
CERTIFICATEO— E�Pf10N FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need raw W complmit eted if the peris for one hundred dollars(SIM)
or its,.)
1 cmifv that in the performance of Ne work for which this permit is issued.I shall not
employ any person in any mannerx as to Wceme mbjot to the Workers Compensation
Laws of Califomi..Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to thc Workw's Compensation provisions of Ne Labor Code,,you most
z foMwith comply with such ProvimmO or this Permit shall W domed mocked.
'ZOPCONSTRUCTION LENDING AGENCY
Ihereby affirm Nat Vert is a Construction lending agency l'm the performance of
Sec dlo work for which Nu permit is issued(Sec.31197,Civ,C.)
QLender's Name
=z Lender's Address
U0 I certify Nat 1 have rad this application and state Nat thea Wve information is
"P carnet I agree to comply with all city and county oh inamcs and sum laws relating to
0U Wilding construction.and hereby mdhOdM mPmRmtativu of this city W color upon the
lihoveties,u g property for i expenses
which may
F y (We).gra to save,indemnify and keep harmless the City of Cupertino against
rn inconsesjudgmf 41'
nandex0'Permit. meq in anywayeccruc against sail City
in eonsequencc of grand"'
thisPermitU z SPP EG NS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date$i nu ofA icr Re-roofsMATERIALSDISCLOSURE alo Type of Roof
Will the appre Wilding ocsmpantslom whandlc haysrdous material
u defined by Ne Cupe i o Municipal Code,Ch,te,9.13,and the Health and Safety
Jc,Sectio 2(a)?
or ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or fulum Wilding occupant use equipment w devices which If a roof is installed without first obtaining an inspection,I agree to remove
emitict9 nus a' ruminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District? c
ONO
1 have mad the hvammss malorinureyuiremonts under Chapter 6.95of Ne Califon
nia Health&SalcyCode,Sections 25N)5.35533 and 25534.1 undersund thmif the building
docs not currently haw M am.that it Is my responsibility N nmlfy IW occupant of the
he has hi ovu met prim W issuance of a Cerafmate of Occupancy.
L 22 Signature of Applicant Date
I tam C D„e All roof coverings to be Class "B”or better