05090027L
CITY OF CUPERTINO�
BUILDING DIVISIONPERT
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BUILDING ADDRESS:
NOVO CONSTRUCTION
PERMIT N005090027
OWNER'S NAME:
PERMIT LSSUEDATE
PROMETHEUS 150
1042 HAMILTON
09/06/2005
E;
SANITARY NO. CONTROL NO.
(650)701-1500
ARCHITECUENGINEER:
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BUILDING PERMIT INFO
BLDG51F.CT PLUMB MECH
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. LICENSED CONTRACTORS DECLARATION
Job T� crl tion
I thereby affirm that I em caudal prevision of Chapin 9 (commencing
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with Salion7pgq of DiWalon 3af the Bunlneu and Profcsilnns Code, myliccnx is
fthe Business
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infull farce and er-I RTI
--NEW WALL �'('„{t
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License Cl Lk.M
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Dam Contractor_
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ARCHITECI'SDECLARATI N
I understand my pans &hill be used a public mmocs
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f Y V 2005
Licensed Prefcuional
OWNER�BUILDER DECLARATION
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lg refor . (Om that 11. exempt from Om Contractors License Law for tui
fallnwin moan. al. that
10313. Business and Pm(essirou Cade: ce cit w Countyjj]J
ry7 ly t ff�ray
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which rquiral a Permit m construct, altar, improve, dcmolah. or repair any structure
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prior to its issuance, aau requires we applicant for such permit in rile a signed statement
Ft. Floor Area
VAlbation
that he is licensed Forward, to the provisions of the contractors License Law (Chapter 9
Sq.
(commencing with Section 7000) of Division 3 of the Business and Profession Cade) or
Nal he a exempt Nemfmm and the boa for the alleged exemption. Any violation of
3
Occupancy Type
Section 7031.5 by my applicant for a pnmft aubjecu the applicant to a civil penalty of
not mise Nan five hundred dollars ($500k
❑ 1, u owner of the property, or my employes with wages u then sox wmpmtu Ion,
Required Inspections
will do tiro work and thea exux, a not invaded oralrertA for sac(See. 7044, Business
and Prorem oro Code: The Commetars came law deal rot apply W an owner or
property who builds or impmvvts themon, and who does such work himself or through his
own employees, provided that such Impmwmenu are net intended araRered forme. It,
however, the building or improvement is said within ane year of completion. the awnen
builder will haw: the burden of proving that India not build or Impmw for purpose of
ala,),
❑ 1, as owner of the propeny. am exclusively contracting with llcemed conuanou in
construct the pmjca (Sec. 7044. Business and Pmfesdans Code:) The Commutes U.
cove Law docs not apply to an owner of properly who Wilde or Improves thereon, and .
who contracts for such projects with a conmector(s) licensed p rrxanl to the Contractors
Lkene Law.
❑ I m exempt under Sea ,B@P C for this main
Owner Dow
WORKER'S COMPENSATION DECLARATION
1 hereby .frim under penally of perjury one of dta following declarations:
1 fawned will maintain. Cenifiate arcanxat m saWmare for Wmkera Compare
action, u provided for by Stttion 7]00 of dv labor CodePerPerformancer the Performance of the
work rte which Na permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, u required by Section
3100 orthe LaWr Code, for the performance of the work forwhich this permit is lasona
My Workers Compensation Insumtce artier and Policy number sm:
Cartier: si - Pala Lr Polity No.: ZOL
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
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(Masectlon reed nolhecnmplemd if the permit a wroom hundred dallmsiSIOB
or less)
1 certify that in the performance of the work for which this permit Is issued, I shill not
employ anypermn in any manner an as to become subject to tM Worker' Compenssdon
Laws of California. Dam
Applicant
NOTICE TO APPLICANT. If, after making this CeniOate of Exemption, you mould
become subject m the Wman's Compensation provisions of the IaWr Code, you most
forthwith comply with such pmvisiom or this permit shill be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them I., comvucUnm landing.gena far dm performance of
the work fm which Na permit is ivuud (Sec. 309'1. Co. C.)
Landers Name
Lenders Adder..
1 certify that I have rad this application and sum that the move information a
contact. I agree to comply with all city and county ordinances and aura laws re1stNg to
building construction, and hereby fothadn represenutiacs of this city to enter upon the
almvbmendamd pmpenY for impcetion Purpmes
(We) agne to save, indemnify and keep harmieu the City of Cupertino against
liabilities.judgments, coW aud expenses which may In my way.mue against said City
In co umta of Iha granting of this pcmit.
LIC NT yttyIIIINDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
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Issued by: Date ( O
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OUR 'E LrONS. Q _f �s
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Re -roofs
Signatum ormppawlinuccommomr Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will Ne applicant or future Wilding occupant pore or handle heurdous material
defined by the Cupmino Municlpl . Chapter 9.13, and the Health add SafetyCode,
C.d.-
Saction 33333(a)1
All roofs shall be inspected prior to any roofing material .being installed.
1-3Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will ft eppIw m or future Wilding occupant use equipment Or devices which
II husrdnus air cmudo fon u dc0xd by the Bay Area Air Quality MamliCh al
all new materials for inspection.
WiclT
❑ Yes V"
I have mW the haurdnus mamriais requirements under Chapter 6.93 or the Ctllfor•
nu Health & SaietyCode, Section 25505.35533 and 21334.1 unwound thu irdm Wilding
dmntly hese a tenant. Nu It u my reapomiMllty m notify Ne acupant of the
reggp pe elpna.cmm�aaay
ranry�
4
Signature of Applicant Date
L _I (QDow—
All roof coverings to be Class "B" or better
Own h rauthori>e agent