05010066CITY OF CUPERTINO
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BUILDING DIVISION' PERMIT
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BUII,DINGADDRESS:
400' STEVENS UK RLVD
HILLHOUSE CONSTRUCTION
PERMIT N005 010 0 6 6
NER'S NAME:
PURMTf LSUB DATE
PROMETHEUS 2ND FL. 245
1670A ZANKER RD
11 2005
NE:
SANITARY NO. CONTROL NO.
(408)467-1000
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
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Job Description
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TI--INFILL WALLS
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Dam � ` U Contractor
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ARCHITECTS DECLAR TION
_dcruand my phos shall he,, .J a public rca/y/f
Licensed Profen ional
OWNER-BUILDER DECLARATION
I hereby affirm Nm I em exempt from the Condamor, License Law far the
following rcuan. (Semon 7031.5, Business and Pmfcuiom Code: Any city or aunty
which requires a permit to ennbaet. alter, harrow, demolish, at repair any structure
$128918
Sq. Ft. Floor Area
Valuation
prior to its ivaana, all. mquircs the applicant for such permit m Ole a signed suumdnt
that he is licensed pursuant to the prevision of the Common's License Law (Chapter 9
(commencing with Section 7050) of Division 3 of the Bushell and profession Coal) err
that he h exempt imminent and me hath for me alleged csempoon. Any violation of
Section 7031.5 by, any applieml for a permit subjects the applicant to a civil penalty oferO
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Occupancy e
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not more than five hundred dollen ($500).
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[I I,u owner ordminapeny, army crodayceswith wages aftheirsoleeompereaoon,
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Required Inspections
will do the work, sod the structure is not intended mattered fors.]. (Sec. 70x4, BOOM.
and Pmfcsslons Cade: The Conusetori Llan. Law does not apply to an owner of
poll who build, or improves Ihemon, end who does such work himself or through his
own employers, pmvided that such improvements an, not intended oroRered forsele.If,
however, the Wilding or improvement is sold within one yell ofcomplMion, me ower-
builder will have the burden of proving met he did not Wild or improve far purpose of
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❑ I. as mvoer or the Profession, what licensed contncmss
y, em ..elusivelyand
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Sec. 7 U.
came La me pmjecl (Sec. 7844, Business and nYwho ns Code:) The Comecon, rad
not apply man who
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whoclawdoesr such withsedpurrimprothe Contagand,
wtemse contracts for pmlecu with ecamm�or(s)licenud pursuant to the Conuutors
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❑lam exempt under Sec. misreuaa
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WORKER'S COMPENSATION DECLARATION
1 barely affmn under penalty of perjury one of the following oalantion:
I ban and will maintain a Cdniftcae of Consent to ulFimum for Workers Compere
urian, u provided for by Section 3]00 of the labor Code. for Jin performance of Jre
walk for which nth permit is issued.
❑ 1 haw and will maintain Worker, Compensation Insurance, Is required by Second
7700 of the LOWr Cade, for the performance of the work for which this permit is lulled.
My Workers Compensation Insurance carrier and Policy n��um��b���.art�:a/l�
Ca' JbIY h)4PolicyNo.:7groc7r'
CERTIFICATE OF EXEMPTION D WORKERS'
COMPENSATION ISCE
(This=Iran reed wt W completed If the permit Is ralae hundred dolls x($1110)
or teas.)
I certify that in the performance of the work for which Ibis permll Is issued, I shell not
employ any person in any manner an as to Wcome subject to the Workets' Compensation
Laws of California. Due
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption. you should
mature subject to the Workers Compensation provisions or the labor Cade, you mum
foMwim comply with such pmvuinn or this Permitahtll W camels nwoked.---
CONSTRUCTION LENDING AGENCY
I hemby affirm that mare h a construction lending agency for the perfurounm of
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the murk fur which our permit Is hulled (Su. 3W7. Civ. C.)
lender's Name
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lardersAdomu
I certify that I haw read this application and sure mal the aWn information H
building I groe to Comply With all city and county nNinsdas and cull laws miming to
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buildingconstruction.and hercbyuthor this city to enter upon the
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shave-mentioned to .. forImpemon keep hu
(We) agree to caw, indemnify eno keep bay me City Cupertino against
,
liecomaccommejudgment, in an res
and expenseswhich they in any way ucrue against uid City
thecosts
Aconuquenee of me grunting of this rmil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
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Issue,Date
SOUgg��p�,��Rg�G�ULATIqq��++S.
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Re-roofs Q
Type of Roof
nurcof Applimu Canuacmr Data
HAZARDOUS MATERIALS DISC
Will the applicant or fusers building oecupa anJlc ha'rutlout materiel
defined by the Cupertino Municipal Cade. Charter 9.12, and the Healthand S.fcty
Cold
Cate, ElYcf 255324)?
All roofs shall be inspected prior to any roofing materia being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will and applicant or future building «spam use equipment or devices which
LL h.ardnus nir contaminants u JcOncd by the Bay Arca Air Quality Management
all new materials for inspection.
trict7
•(]Yes No
Ihave mW the Wmm
aare materials mquimmcnu under Chapter 6.95ofthe C.lifor-
rahHealth & Safety Cade. Socoon 25505,25537 and 25534.1 undcmuM mm if the Wilding
rima not currently haw a tenon mm in is my responsibility In nnti I the occupul of the
myvimmcnuw hark mast x,9let pngr 1.iuuanaerr. CeniM' of Occupancy.
Signature of Applicant Date
YY (AWP
All roof coverings to be Class "B° or better
nir or authorized
agent Data