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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CONTRACTOkANFO,RMATION
BUILDING ADDRESS:
NOVO CONSTRUCTION
PERMrrN®4090286.
0400 STEVENS CREEK BLVD
OWNER'S NAME:
PERMIT ISSUE DATE
.,PROMETHEUS
420 MAPLE ST
10/20/2004
NE:
SANITARY NO. CONTROL N0.
(650)701-1500
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDGPLOr MECH.
J O O
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby afnrm that 1 am licensed under provisions of Chapter 9 (commencing
p
wiNScef`o n 7Bg))afowismn Softhe Ode and Profcesions Code.and mylmemet,s
it mu mrdga I
affra .� /0 ZLy
TI --INSTALL ADA STAIR LIFT
Ls. so Clam Lic. Is
Dams n— 6 C.atfsmor ova
(MAIN ENTRY)
ARCHITECTSRATION
I
undcrstanJ my Tionreords
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby aliform that I am exempt from me Connemara License Law for the
following reason. (Section 71* 1,5, Business and Professions Calc: Any city or county
which mqulres a permit to Crammer, aI., improve, demolish, or rural, any snucmm
prior to its issuance, also requires the applicant forsuch Permit to file a signed statement
that he is licensed Torment to the provisions of the Contractor's Limn¢ Law (Chapter 9
Sq. Ft. Floor Area
Voggiolm00
(commencing with Section 701)0) of Division 3 of the Businev end Professions Code) or
that he is exempt mciefrom and the baso for the alleged exemption. Any violation of
APN Number
D Occupancy Type
Section 7031.5 by any applicant for a psmtlt subjects the applicant to s civil penalty of
rat more Nan five hundred dollen (25007.
36901028.00
I, as owner of the propcny, or my cmploy,ca with wages as their sole eompensatlrn.
Required Inspections
will do me work. and theawcmm isnot intended or offered for sale (Sec. 70,14, Buxiws
and Pourmlons Code: The Communes License law Coca not apply to an owner of
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property who builds orimprom menton, and whodoes such work himself or through his
own employees, provided met such improvements are not intended or offered for ale. If,
how..,, the building or improvement is sold within one year of comple ion, the owmr.
builder will have m, burden of proving that he did not mild or improve for purpose of
sale,).
1. as owner of the property, em eaclmively contracting with licensed counsel. to
construct the ymjcet (sec. 7044, Business and Professions Code:) The Contractor's Li.
cense law docs not apply to in owner of property who builds or improves thereon, and
who contracts for such projects with a contnmor(s) licensed pursuant o the Contractor's
j.tynx law.
191 em exempt under Sec. . B 6 P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby af0tm under Penalty or perjury One of Lou following declarations:
I have sod will maintains Ceniftcateor Conunttoself.insumfor Wor esCumpem
on, u provided for by Section 3700 of the Labor Code, for the Performer. of the
work for which this Permit is issued.
❑ I haw and will maintain Workers Compensation Insurance, as required by Section
3700 of me labor Code, for me performance of the work for which this permit is issued.
My Workers Compensation Imummec carrier and Policy number art:
Cartier. Polity deg:
CERTIFICATE OF EXEMPTION FJPDVIWORKERS'
COMPENSATION INSURANCE
v
rfhts ucurm need not nccompmmd Ione permit Is for one hundred dent,. (tlBln
,it less.)
,
I emir, mat in dLe rtprmancc of me work for which mix permit is issued, l shall not
cmployany pc many mann Olrmcorn o ject to the Workers' Compensation
Laws of Californ' am `
Affffpppplijjjqato /IYQ.
Nriy[E TO PPL CANT: If. aft r making this Cenifinm of Exemption, you should
h tcbNroa subject to the Worker's Compensation provisions or the Lahor Code, you most
forthwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby &Mom met there Is a constroction lending agency or the Pcrroormna of
me work for which this permit Is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Addmu
I certify that 1 have read this application and state that the shove information is
Conor I agree m comply with all city and county aNinanms and runt laws relating to
building convection, and heathy authonre representatives of this city to enter upon the
abate -mentioned property for W peeuon purposes.
(We) agree to saw. malmmfy and keep hsrmkss the City of Cupertino against
liabilities, judgments. costs and expenses which may in any way accroe against said City
in conuyucnc ftha graming of this Permit.
APPLICA NDERSTANOS ANI,t. COMPLY WITH ALL NON.POINT
Issued by:S Date
SOURC ULATtONS.
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Re -roofs
gatetureofApplic•ntiCofforactor Data
HAZARDOUS MATERIAISDISCLOSURE
Type of Roof
Will me applicant or future building occupant store or handle hamodous material
as defined by the CuMnino Municipal Code. Chapter 9.13. and the Health and Safety
Cotte. Section 25533(a)7 ,I�f
❑Yes
All roofs shall be inspected prior to any roofing material being installed.
NNu
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future buildingoccupnnt use equipmcnla, devices which
sit hamnlous air conuminens as defined by the Bay Arca Air Quality Management
all new materials for inspection.
xric.?
C] Yes (KNu
1 have mad the hmarduua materials requirement, under Chapter 6.95 of the Califor.
ria Health a SafCyCnde. SeNom 25515.35533 and 35534.1 undersand that iflM building
arm not cu y hate a moan.. met it i pomobility m modify .he oecuPant of me
mquiruma khmes.beme anmnr.CenlficateofOempaney.
Sig nature of Applicant Date
All roof coverings to be Class "B" or better
mer ser atumn,ed.;Cut Data