03100167CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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CONTRACTaQRINFp'RMATION -�
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BUILDING ADDRESS:
REDWOOD CITY ELEC
PER M IT NOO 3100167
SR's NAME:
114 HAZEL AVE
PERMIT ISSUE DATE
PROMETHEUS
10/23/2003
NE:
6503695555
SANITARY NO. CONTROL NO.
ARCHITECDENGINEER:
BUILDING PERM IT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION -
job Description
I hereby affirm that 1 am under provisions ofChapterCode. 9 (commencing
p
with Section ]pXp of Division J ofthe Business end Professions Code. and my license is
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LfuHf orce ary�yffact.
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UNDERGR ELECT FOR SIGN �'NALE®
Amy Comm��ct9955 O //G�m F/cc
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X/ARCHITECTSI)DPLARATIION
I understand my plans shall he used u public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
fallowing reamn. (Section 7831.5, Business and Professions Code: Any city or county
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which requires a permit u, construct, alter, improve, demolish, or repair any structure
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prior Ba its issuance, also requires the applicant for such Permit to file a signed statement
that he is licensed pursuant o the provisions of the Commcturh License Law (Chapter 9
Sq. FL Floor Area Valuation
(commencing with Section 7") of Division 3 of the Business and Professions Codc) or
36901028.00
Out be is exempt Nc¢from and Ne basis for the alleged exemption. Any vicla 1, a of
Section 7031.5 by any applicant for a Permit ubjects the applicant to a civil Penalty of
APN Number
Occupancy Type
not more Nan five hundred dollars n2hdd).
P Y YP
or employees with wages their sole camper
❑ Las owner of the pue
and the he Contis tor& tended License La dosed not apply t o44, Business
ncet i. r sins,
will do Professions
and Professions The C License Law data tart apply m an owner
Required Inspections
propown erty who or sBacrmr`a
himselfor his
id dwho is
-
mployeesbuilds provided edthrough
employees, provided Not such improved ire not intended
Oat suchere not intended moeered forthe sale. 1E
how
however. the building or improvement is said within one year of completion, theowner.
wit owner.
builder will have Ne burden of proving Net he did not build or improve for purpose of
of
u1cJ.
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
coosthel the pmject (Sec. 7044, Business and Professions Code:) The Contractor's I.A.
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to des Contractor's
Limense Law.
❑ 1 am exempt under Sec. , B & P C for this reason
Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury, one of the following declarations:
1 ttcri
have and will maintain a Certificate of Consent self-Tnsum for WorkCompen-
sation, as provided for by Section 3700 of NN
e labor Code, for e performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, m Required by Section
3700 of Ne Labor Code. for the performance of be work for which this permit is issued.
'
My Workers Compensation Insurance carrier and Policy number art:
Cart AF �I/ LaJ. ns A,6- Policy 70. WC 7/V SIG
CERTIFICATE OF EXEMPTION OM WORKERS'
COMPENSATION INSURANCE
(Thu section need notlee completed if the Permit is Torch hundred dollars III
om less.)
1 cenify Not in the performance of the work for which this Permit is issued. I shall not
employ any person in any manner so as to become subject to the Workcri Campensation
.
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject to the Worker's ComPcnution provisions of the Labor Coca, you must
forthwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby aRfm Nat there is a convection lending agency for the Performance of
Ne work for which this permit is issued (See. 3097, Civ. C.)
Lenders Name
Lender's Address
1 certify Nat 1 have mad this application and sum that the above information is
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coned. 1 agree to comply with all city and county ordinances and sum laws relating to
,
building convection, and hereby auNmiae AePresentadWS of his city to c nch"pon the
above-mcntiuned property, for inspection purposes.
(We) agree m sew, indemnify and keep harmless the City of Cupertino against
Iiabilitiu, judgmcnm. casts and expenses which may in any way same against said City
In consequence of the granting of this permit.
APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATI
%0 ? 3 c,
Re -roofs
Si wrc of ApplicaDeer Date
HAZARDOUS
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or (Muni building occupant stare or handle ha�ous material
c(Ined by the Cupertino Municipal Calc, Chapter 9.12, and the Health and Safety
c, Section 25533(a)?
❑Tea px!�
All roofs shall be inspected prior to an roofing material beim
P P Y g g installed.
Will the applicant or future building occupant use equipment or devices which
ls�t,
If a roof is installed without first obtaining an inspection, I agree to remove
hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
iet,
❑Yes 01<6
I have mad Ne h sholm smamrials requirements under Chapter6.95 of the other.
niaf alO&Safcty Codc,Sccdons75505,25533and25534.1understandthatifdm building
does not currently haw a renin, Out it is my responsihiliry to notify [be Occupant of Nc
rcquimmcmvwhichmustbcmet'onnismancenfaCcnifcamorOccupancy.
.SlgnatUCeofAppllCant Date
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All roof coverings to be Class " o or better
g
Ow r too rixed aF t Doc