05050159I
[i C
�V
UC
UC
"0-�++ E
FQ
U2
I
CITY OF CUPERTINO
an *^I_111171777177�^'�s
MATION
BUILDING DIVISION PERMIT
"'C'0xTRAGT()R,NFU
BUILDING ADDRESS:
HILLHOUSE CONSTRUCTION
"Bab"T"005050159
OWNER'S NAME:
PERMIT ISSUE DATE
PROMETHEUS 6TH FL.)
1670A 7ANK7R RD
nc)r)
NE:
SANITARY NO. CONTROL NO.
(408)467-1000
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BIRO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 bermy affirm Nal 1 am limnmd under provisions of of Chapter 9 (mm ecru in{
P
wide Section 7073) of Division 3of dm BLLVnCY Nd Pmf..,i.. Gude. and my license 1a
in full forte and effort SS - 9'
REVISION --ADD 4 OFFICES
Licence Clue Lk. g
Dam ` Connector ca,,dim�
NO NEW PERMIT ISSUED/ ORIG. #05040100
ARCHITECTS DECLARATION
1 understand my plana shall he used u public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hemby affirm that I am exempt form the Contra°oh License Law for the
following muom (Section 7031.5, Business and Profusion, Code: Any city at county
which requires a permit to construe,, tlkr, improve. demolish, or repair any structum
poor m its issuance, also requires the applicant for such Permit to file a signed statement
that Welicensed pursuant mNepmvisiouofbeConuacmriUccomeLaw (Chapter 9
Sq. Ft. Floor Area
-
Valuation$35
(commencing with Section 7000) of Division 3 of the Business and Profession, Code) or
that he Is exempt therefrom and the bub for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by soy appllnnt for a permit objects the appliunl W a Civil penalty of
net more than five hundred doliare (S50o).
36901028.00
O I, a owner of the propeny, or my employees with wages u their sok compensation,
Required IeCIlOnS
e ns's
will do the work, and the anaclum Isnot Intended eroffered forsake(Sec. 7044, Business
License Law deer t apply m an Owner ar
and Profusions Code: The Cemmtomne
9 p
propeny`s'ho buildsorimproves the en, and who doessuch work himselforthrough his
own employees, provided that such improvements tee notlnende l or offered rename. if,
however, the building or improvement Is mid within one year of completion. the owner.
Wilder will have site Wrden of proving out ha did not Wild or improve for purpose of
ark.).
❑ I, as Owner of the propenY• am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Bwlness and Profusion Code:) The Coomcmes U.
cenee law dote not apply to an owner of property who Wilds or improv thereon, and
who contracts for such prokcu with a eonyacmr(s) licensed pursuant to the Comnctor's
License Law,
(^
v
O l am exempt under See. , B k P C far this moon
Owner Date
.J
WORKER'S COMPENSATION DECLARATION
1 hereby aim under penalty of Perjury am of the following declarations:
I have and will maintain a Cenificate of Consent mlhksu a for Wmetes Compere
amian, u provided for by Section 3700 of Ne labor Code, fen the performance of the
workfor, which this permit is leaned.
❑ 1 have end will memoirs Work er Compensation Insurance, u required by Section
5700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workeh Compensation Insurance Carrier and Polity number are:
Cartier.-/.� v 9-A— Policy No.: /YSO eAR%`
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mus section need not W completed trill permit isforonehundred doBau ($100)
or less.)
1 certify that In the performance of the work for which this permit is LuucE, I shall not
employ any person in any mannel an u to tamme subject to the Warkeri Cempeneadon
'
Laws of Califomis. Date
Applicant
NOTICE TO APPLICAND IL after making this Cenincam of Exemption, you should
became subject to the Worker's Compensstien provision of the Labor Code. you mum
forthwith comply with such provision Or this permit NJI W Commit meted.
..
CONSTRUCTION LENDING AGENCY
1 hereby affirm that then its construction lending gency for the Performance of
the wurk for which this permit is issued (Sec. 3097, Cih, C.)
Lmdefs Name
Lender's Address
1 mnify that I haw read this application and sou thn the aWve inromatlon is
coram I agree to comply with all city and county ordinances and rate laws misting to
Wilding convection. and hereby anthodm Min emntstiws of this city to cnur upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep batteries, the City of Cupertino agsin,
j Ilabllides, judgmenu,casu and expenses which may k my way accrue straiten d City
inco
APPPLLICANT UNDERSTANDStAND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
SI{namm of App!icmVCCm x%r Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
WIII the applicant or future Wilding amupanlseorc or handle huardous material
u defined by the Cupertino Municipal Code. Chapter 9.13. send me Health and Safety
Codeea 2ss32(a)7
All roofs shall be inspected prior to any roofing material being installed.
C1 Yea Otho
C1
If a roof is installed without first obtaining an inspection, I agree to remove
Will the.7l.anl or four Wilding mupam e19. eyuipmcnt or devices vehicle
It havardou air contaminants u defaced by the Bay Area Air Quality Management
all new materials for inspection.
District?
Oyu Otho
I have mad the huamms materials requirements under Chapter 6.97 of the Califon
nia Health A,Safety Cade, Section 35505, 25533 and 35534.1 understand that lfthe Wilding
does not currently have a mans. the, it is my responsibility to notify due compact of the
mquimments which mum W mel pier m mCa lssuof a Ccnifcau ofa Pa( �^-
)' /
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or aumorired agent Date