04090035 CITY OF CUPERTINOBUILDING DIVISION PERMIT QQNTRACTORINFORMATTON. -Ax-
BUILDING ADDRESS: FLUID INDUSTRIAL SYSTEMS PERMIT NO 04090035
OWNER'S NAME: PERIATI'MUEDATE
STEVENS CRE
NE: SANITARY NO. CONTROL NO.
(408) 947-7700
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
.�zep tp LICENSED CONTRACTOR'S DECLARATION Job Description
I kmby affirm Nat I me limmed under provisimu of Chooser 9(commencing p
with Section 70114).fDMinom Sof NC Busiotys i Prof ruu s ode.and my 11
^O in4a1(fora and crceq. ✓ �C� "Y PLAN CHECK REPEAT FEE ONLY
License e� Lie.N
z. Oslo conlrecmr
W7< ARCHITECTS DECLARATION
1 understood my plans mill k used u public menrds
p�U
3
Licensed Professional
OWNER-BUILDER DECLARATION
affirmaffirm \
i F I hereby athe 1 m1. nfrom N.Contractor's License Law for the
p O following moron.(Section]1D 1.5,Beat.uainass and ow.Profession Croix:Any city m county v
$ which requires a permit r enres Be,,altar,minnow.demolish,or repair any ewnum
FZ< pdmmitaiuuence,also
eara in allovisio sumso 0.Cohpermi's.aaLaw(ned statement
Y (commencing wi pumunt m Ne of Division
of the GonbmtofelJanseuJw(GkdICr9 Sq. Ft.Floor Area �Val/YsfC{On
K�p (cat he
ngwithourfoureand of hams n3 Baleged..ness and...A,violaMe)or
Net k u exempt Nertfmm and Ute baso for Be,alleged eumption.Any violation of '
Section 7031.5 by any applicant fora permit subjects the applicant o a civil penalty of 3 2R142Jd 54bcr 0 0 Occupancy Type
nut mom Nan five hundred dollars(MM).
❑I.uowtv4of Nepmpeny,mmycmployceswlthwgauNeirmlemmpenudon,
wiildothework.anddloslmetumisnotinsendedaraQem rorstic(Sm.7W,Busircu Required Inspections
and Professions Code:The Cmemactofs Limme law it=not apply to e ns an owner of - q p
propeny who builds or improvm Neroon,and who does ouch week himself or through his
own employcce,provided that such improvemenuare not intended oro@red formula.If.
however,the building or improvement is mid within one year Of completion.the owner.
builder will have du burden of proving Net k did not build Or Improve for purpose of
.to I.
❑1.as Owner of the promng aot exclusively contracting with licensed contractors in
cunstmct the project(Sec.7014,Business and Professions Cade:)The Con ructer'e Li- _
Came law does not apply to an owner of property who builds or Improves the eon,and
who contracts for such pmleets with a eontnctot(s)licensed pursuant to the Contractor's
License law.
1 and exempt under Sec. .B t:PC fm Nis mamn
Owner Dote
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury am of the following declandons:
haw end will maintain a Ceru fane of Consent to self-insure for Workers Compcm
tion,u provided for by Section 3700 of the Labor Code,for to performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,m;required by$cellon
3]00 of dm laborCode,for Be perfomance oftk work forwhich this permit is issued
My 7kk5r-',Co nation Insunna carrim end Poll,number art:
CameLYEG�uA4M�OF&ON6 .:N RKERs �✓J
ERTIFIC O OF L%EM�ON. OM WORKERS
COMPENSATION INSURANCE ,
(This maim need not be completed If the permit Is(orotic hundred dollars(SIM)
or less)
I unify that in to pmfomanco of tk work for which this pemit is issued.I shell nm
employ any parson in my manner se as to become subject to the Workers'Compemmkon
Laws of Cuifonia.Dau
Applicant
NOTICE TO APPLICANT:If.air making this Ccnificatc of Exemption,you should
become subject to Ne Worker's Composition previsions of Be Labor Code%you mum
0 faMwida comply with such prevision or this permit Nall be damned revoked.
,z„r"" CONSTRUCTION LENDING AGENCY
E—t 4 thereby affirm Nat Nen is construction lending agency for the performance of
C4 tom„ the work for which this Permit b issued(Sec.3097,Civ.C.)
4 G Lender's Name
= z Lenders Addreu
U O 1 modify Net I have nod this application and solo that the man.information is
ECOMM 1 agrR In Comply with all city and county ordinances and same laws Calming m
Q building construction,and hereby authorize repnsenteives of this City t0 color upon thc
above-mentioned peeper for inspection purposes.
Lbw, (we)ague tO tow,indemnify and keep harmless Ne City of Cupertino quos
L�I,, liabilities,Judgmcnu,costs and expenses which may in my way*cc=against sod City
of OC
C) in^ APPL consequence
nCeLINGERSnunga 0 WILL COMPLY WITH AL NO -POINT Issued by: Date
50 LA 5 O
Re-roofs
Si mo! VC.ntnctor y,Z Delo
HAURDOUS MATERIALS DISCLOSU Type of Roof
dl y the
Cupertino
no forum killing aceupmumn m handle hvsrdous malodu
caned by the CupertinoKut1.0*"flding
l Code.Chapter 9.11,and the Health and Safely
Code. 10
Section zss3xa)? - All roofs shall be inspected prior to any roofing material being installed.
❑Yee
Will the applicant Or occupant me equipment or devices which -If a roof is installed without first obtaining an inspection,I agree to remove
I
harardnm sir cmtaminany u dc(imd by Nc Bay Area Air Quality Management all new materials for inspection.
trio?
Yes
1 kw mad Ne haaardme mamrials requirements under Chapter b.YS of the Califor-
niaHcalNhSafety Code.Sections 25505,25533 arv1255th.I welcomed that Idiot
doesnot cummlyhe ..'risibility t.Nato u my msibility to n ofdc
mquimmcm w' he
a fa CcNBcam ar u y.Q S ignature of Applicant Date
Owner or vedspot em All roof coverings to be Class"B" or better