04120054CITY OF CUPERTINO — "- •'..
7777
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BUaowc DrvSstoN' PERNIIT
OPFITOR1��rl�
BuiLDINGADDRESS:
NOVO CONSTRUCTION
PEBMITN%4120054
20400 S CK
OWNER'S NAME:
PERMIT ISSUE DATE
PROMETHEUS REAL ESTATE
1042 HAMILTON COURT
12/22/2004
E:
SANITARY NO. CONTROL NO.
(650)701-1500
ARCHITECDENGINEER: _
BUILDING PERMIT INFO
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BLDO ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Descri tion
I hereby &Man that I on licensed under provision of Chapter 9 (commercial,
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wish Sudan 7000) orDivalon 3 of the Bud. and Prafeuiou Code, and my Henna is—'-
infail [a.andeffecL '-
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License Class Lmar
Deas Gaa DEC
ARCNTIECI'S DECLARATION
' 1 undemanJ mY plum shall k uud as public mmrda
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Licensed Professional
OWNER-BUILDER DECLARATION
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I hereby alErse that 1 am exempt from the Conuaclo'l License law for the
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rallowing moon. (Sudan 7031.5, Business and Profession, Code: Any city or county
m Improve, demolish, Or repair any stnecmm
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which requires a permit ennwuct, alar.
to fileamaultue
t forsuch paRtemm
priorm its isnnco.shu requima0uspplitanm
he is licensed pursuant Ne provinces of Ne Conuumr'sUcenu low (Chapter9
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Sq. Ft, F1004fl�reid
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(commencing with Section 7010) of Division 3 of the Businessand Prolamines Com)or
that he is exempt thamfrom moldthe basis far Ne alleged exemption. My rlolatlon of
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,Occupancy Type_...
Section 7431.5 by M applicant for a permit subjects the applicant in a civil penally of
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not rent, Nan five hundred dollars ($500).
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❑ I, as owner ofthe property, ar my employes with wages u their sale cumpereadon.
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Re uired Inspections -
w delbewark.mdNeswaumisnotmmnde4oroReudfarale(Sa.70W,Busies,
and Profanaas Cade: The Cutaneous License Law doss nut apply m in owner of
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properywho buildsorimprove, thereon. and whodoessuch work him elfin through his
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mnemplayccs,pmvidcdN.tswhimpmv m,.ammlimmndedaroQemdfnrade.If.
hawev. Ne building or improvement is sold within am year ofcempletion. the owna.-
builder w10 have she burden of proving Ihel he did not build or improve for peapod, of-
ale.).
1, as owner of the property, am ucluively contracting with licensed contractors, to
comtmcl the pmject (Sec. 7044. Bestow and Nofesnom Code:) The Canrrecmr's U-
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Cans, Law does not apply to an owner of property, who builds or Improv Noreen. and,-
whocontracuforsuchprojeclawishacom aaad0 licensed pursuant to Ne Conammes
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❑lamacmptunder .B&PC for this
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WORKER'S OMPENSATION DEC
I hereby affirm under penalty of perjury arc of the following decluaNam:.-
him and w111and uinaCartifinu of Commul to uhf-imam far Worker's Compcn-
sa lon, as provided for by Sudan 37M of Ne labor Cade, for she performance of the
work for which this permit is issued.
❑ 1 haw and will mania Worker's Compensation Insurance, as mguirod by Section
3700 of the labor Code, fa the performance of the we* for which this Padilla Issued.
My Worker's Compensation Insunn m carrier and Policy number am:
Carder, Polley No.:
- CERTIFICATE OF EXEMPTION FROM WORKERS'
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COMPENSATION INSURANCE
mossatlm need nnt4campleme drum, Permit is forauhundsed lotan(5100)
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m less.)
I comfy that in the performance of Me wark for which this permit is issued. I shall not
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employ any person in my manner an u m become subject to the Workers'Compensation
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Laws of Califomia. Dam
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Applicant
. NOTICE TO APPLICANT: If, after making this Certificates of Easmption, you should
become subject to the Womm's Compensation provisions of Ne Labor Code. you mesal
forthwith amply with such provinces m this purait.hall be dcemW naked.
CONSTRUCTION LENDING AGENCY
1 hereby e1Rrm Net Nen Is a construction lending agency for she performance of
the work for which N4 permit u issued (Su- 3097, Civ. C.)
Lamim's Name
Lender's Address
1 certify that I haw mad Nis application sed suss that the dhow information is
cones I ages, to comply with all city old county a dinarca and sou law, relating as
Wilding construction. and hereby authorize rep cum uuv of Nis city to color upon Ne
{hove-mentioned property for Impaction purposes
(We) agme to aw, indemnify and keep hannleu the City of Cupertino against
liabilities. judgmenu, cards ad expenses which may in any way amore agatasl aid City
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in consequence of the granting of this permit.
APPLICANT UNDERSTANDS OMPLY WITH ALL NON-POINT
Issued by: Date
RCEREGULARe-roofs
Type of Roof
murcofApplican naacmr eatH RDOUS MATERIALS DISCLOSURE
W ll Ne applinnl a future building aecupant a.mof Media hicuNoas mauniafined
by the CupeNno Municipal Cade, Chapter 9.11. and Ne Health and Safety
:ict?
s IyiM sss31(a)?All
roofs shall be inspected prior to any roofing material being installed.
❑Ya \hNo
If a roof is installed without first obtaining an inspection, I agree to remove,
Will the applicant or future building M upant Jm equipment or devices which
hameda.. air conumlmms u donned by the Bay Area Air Quality Management
all new materials for inspection.
❑Yes '((No
I have read the hanrdoua materiels requimmems under Chapter 6.95 or the Califor.
nia Health& Safely Cade, Stuart 25505,15533 and 25534,1 understand that ifthe Wilding
does col eurrenlly hew a tenant that it is my m ismedhilily m unify Ne muPant of the
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1T`utawhichahem Tann Ora ccnirm.m afocnpsncy
Signature of Applicant Date
All roof coverings to be Class "B" or better -
Owner m auNadw gal Date