06020050 - DEMO CITY OF CUPERTINO ``�°�* %�€,`�'
BUILDING DIVISION PERMIT .�CONTRACTOR�INFORMATION
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BUILDING ADDRESS: PACIFIC STATES ENVIRONMENT 15""ITND06020050
20955 STEVEN2
OWNER'S NAME: PERMIT ISSUE DATE
PACIFIC STATES ENVIRONMENT L11555 DUBLIN BLVD 03/08/2006
SANITARY NO. CONTROL NO.
(925) 803-4333
ARCHITECT9ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
�Op LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm IMI i am limvud under provisions of Chapter 9(commencing P
with Sermon 7")of Division 3 of sha Box.and Profeaians Com.and my liccvc u
infmllfaroea. if �(Zj � COMMERCIAL BUILDING .DEMO
Liccnec Cl s Lic.p
,7117 _ (OLD ANDERSON CHEVROLET)
In
vow Daoe' IundermndmyplanssshalllMussedas;public records PD 2/9/06 FOR BL RENEWAL PACIFIC STATES
T o Licensed Professional
` OWNER-BUILDER DECLARATION
g'<x 1 hemby Option that I am exempt from she Canlnctor's License Law for IW
OO following¢axon.(Secuon 703 1.5,Business and Professions Code:Any city or county
K 2( which requires a Permit m cooswct.aher,improve,demolish,or repair any Structure
LZT prior to its ismanoc.also requires the applicant for Such Permit to file a Signedmatement
<
that Mislicemodpursuant tothe provisions offtComment"Ueenv:Law(Chap¢r9 Sq.FL Floor Area Valuation
y�$ (commencingwiShSttlion70W)of Mi ion3nf Ne Busine dPmfeuions Code)or [173000
y thm M u eSemPL therefrom and the basis for the alleged exemption.Any violation of Y
Section 7031.5 by any applicant for a pewit subjects the applicant m a civil penalty of APN Number Occupancy Type
net ream ren live hundred dollar MM. P Y YP
❑I.uo'.vnerof Neprvpmy,amyemployttawio wage ulheirsol=wmpewun,
will do the work and On,structure is not intended or offered to,Sa o(Sec.7x44,Business
and Prefousians Code:The Comments's Lt..Law does not apply to an on,of Required Inspections
property who builds orimpraval thereon,and who duessuch wart himself orthrough his
awn cmployoct,provided that Such improvements are not intended mafiered forsale.If. n
however.She building or improvement is mid within one year of completion.the owner
builder will have She burden of proving But he did not Wild or improve for purpose of
sale.). O C
❑1,as owner of She property,.Business exclusively cnuacting with:teemed camncton m V\
veru La the pmK"(Sec.7044,werofand nywhat Wilds
Cade:)The Cnlmars and
chase law does not apply a an owner of propeny)wM Wilds ar improve therron,and
whocontractsLa ts for such proKcts with a contractor(a)licensed pursuant m the Contractors
0 I ren Law.
❑I ore ucmpt under Sec ,B&P C for this reason
Owmr Date
WORKERS COMPENSATION DECLARATION
1 Mreby affirm under penalty of perjury,one of She following declarations:
I have and will ommuln a C"uftcam of Canaan lm self-insure for Worker'sCompo-
Smion,u provided fm by Section 37M of She labor Codc.for SM performance of the
work for which this permit is named.
❑1 have and will maintain Workers Compensation Iwramm,as required by Section
37Wof than labor Code.for the performance of she work for which Shia permit u banned.
My Worker Compenan on InwrnK artier and Policy num r art:
Carrier, RTIP P PoliPolicyNo.: 7
CC ION FROM WORKERS'
COMPENSATION INSURANCE
(Mia seniorneed not W cempiceed if SW .it is foronc hundred dollen($100)
or leas
1 ttNfy that in to performane of the wart for which this Permit is issued,I shall not
employ any person in any manner an a to become subject to she Workers'ComPeruaun
laws of Califomia.Dau
Applicant
NOTICE TO APPLICANT.If,after making this Cenifcate of Exemption,you Should
become Subic"to the Worker's Compewtion provisions of the Labor Code,you most
.J O famwith comply wish such pmviuons or this Permit shall he dcemed revoked.
'Z" CONSTRUCTION LENDING AGENCY
P4 1 Mmby affirm that Nem its construction lending agency for the performance,of
ce> she work for which Shu pewit is issued(sec,309'1,Cih,C.)
Sanders Namc ,
Z)z Lender's Address
f,Q 1 citify that 1 have read Shia application and auto Sh.r She above womlaun is
F-' nrmct-I agree w comply with all city and county ordinances and sum laws miming m
0 V Wilding construction,and hereby amhorim MPmSanutivea of this City to enter upon the
H Gabove mentioned pmpcny for inspection puryosea
(We,)agree to Save,indemnify and keep hawleas she City of Cupcnina against
to liabilities.judgments.costs and experms which may In any way accma against mid City
t),z A APPLICANT
of she jormuRSTA g of this D WI
^-' APPLICANT\pAUNDERSTANDS AND WI COMPLY WITH ALL NON-POINT Issued by:so RE An) di Date 6
Si jnazrned ppU rtn✓Cn1mamm ���
Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will she applicant w forum Wilding occupant store Or handle haSallous material
az defined by dm Cupertino Municipal Code.Chapter 9.11,and NC Health and Safety
Code,section 35532(x)?
0y. C]No All roofs shall be inspected prior to any roofing material being installed.
OWill the applicnl of future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
il hsvardous air Contaminants as de0ned by NC Bay Area Air Cosily Management all new materials for inspection.
District?
❑Yes 0 N
1 have mad she hvsNnms materials requirements under Chapter 6.95 of She Califor-
nia Hualthh SafctyCere.Sections 25515.25533.11534.1 under and Shut irthe building
Jars cool cuwndy by a nL my maponsibiliry to
Ne,mcupnt of NC
rt mcnswinch Pri m caar,ceoumeof Signature of Applicant Date
suer ar nZnrod agent D te All roof coverings to be Class "B"or better