08040194 CITY OF CUPERTINOi:�z�w•s• s,r5.:id
BUILDING DIVISION PERMIT CONTRAGQRI �QRMATI0IV
BUIhk PERMIT NO.
Lt2lttQpjlQR'kEVENS CREEK BLVD ABLE MAINTENANCE 08040194
NEWS NAME: PERMrIISUEDATE
SHELL OIL CO U S 3224 REGIONAL PKWY 09/10/2008
PHONE: SANITARY NO. CONTROL NO.
(707) 545-5522
ARCHITECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
o ij LICENSED CONTRACTOR'S DECLARATION
W
1 hereby sifter,Wt I am licensed under provisioner of Chapter (commencing Job Description
Mwith Section70110)ofDi,Wo.3oftheBusinessandProfesdumCode.andmylicensee INSTALL ENHANCED VAPOR RECOVERY SYSTEM @ SHELL
in full forte and effect
>qg Lkense Lk.+ SERVICE STATION
DonkGon DEC •eL
ARCHITECTS DECLARATION
m V 1 understand my pole Nall W mod as public rarords
gq
o Lkemmd Professional
3OWNER-BUILDER DECLARATION
I
hereby of".that 1 am exempt from du Centmmofs License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
which rtquiv a permit to cmatrett slut improve,dctnmem.at rimer my structure
prior ho its itName.alar,mqumes the applicant forbueh remit to file,a signed statement
F�c wt W is licensed pursuant W the provisions of the Comraemr•s license Li-(Chapter9 Sq.Ft.Floor Area Valuation
$
(comencrecing with Section 71)(00)of Division 3 of the Business mud Protifessions Codicil or $15000
— that he Is exempt therefrom and the buis for the alleged Compilers.Any violation of
Sectim 7031.5 by my,applicants fee a permit subjects due applicant to a Civil penalty of �,p�T Number Occupancy
notmmethanfw Eundrtddollass(SM • 32631021 .•l7'(/' P Y Type
0 I,u owner of tic pmpcny,m my=Ploycn whb mgr,u Webmle mmpcmdw.
wits dr thewoess sed a: swcwrtbnoes Lica an Law dos act apply in an B owner
of Required Inspections
ProPro arty wh ou Cade:M Crevactot,and
who Law don ren apply lf an rwner of q p
Cum enYwho Wild mimthaw thueon,ChM who=notimworkN antlered
his
wnempkyenilding r i that anchimpmwmcouin ne year funical moQeml fee the owma.a,
however,theWildingOngmimPmwmmtemld did
not Weldofmproefo,ticowner-
buildm will luw Ore burden of proving that W aid not Wild m Improve far purpose of
tale.).
0 1,as owner of the Property am uclusively contracting with limed contractors b
mnmuct the project(Sec.7014.Business and Professions Code:)The Cmvactors U.
eeme Law does mot apply to an owner,of property who Wilds or improv themon.and.
who contracts for much projects withacenursome )licensed".net or the Chrsactors
I i,ma,law.
Iamememptunder5ce ,B&PC(mthiortawn
Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the,following declarations:
re.a provided
ri e maintain•Ce 3700 of the L t m se161uure fm orromm ce of the
ntirn, r provided for miSectionise3]00 of do labor Cade.for rhe perfrmasce of do
work for which Nu Permit ts inrsca
0 1 have and will maintain Workers Compensation hmrance,as required by Section
3700 of the labor Code,for the perfeamance of the more fon which this permit u imued
My Wmkp�.CC�ompenation I..nrtilm and Policy number art:
Carrier:tlerawdy� rC P�75t12Ia yPolicy No.:_ 27A-:a,5050
CERTIFICATE OF EXEMPTION ION FROM WORKERS'
COMPENSATION INSURANCE
flbe mins teed mtMemnpkuJ HNe Rrmit a fmone hun0ed do0us(SI W)
nrku)
1 ratify that in thee perform.of the work fee which this permit a issued.1 Nall not
employ any person in my summer an u in become subject in the Wulns'Compemauon
Laws of Califrmis Dau:
Atpliunt
NOTICE TO APPLICANT:If,after making the Ccr ifcau of Exemption,You should
bccume subject to the Wor s Compensation prevision.of the fa Wr Cane.yen most
.,O forthwith comply with such povidru m the pewit Nall W decmd remkcd. ..
Z y CONSTRUCTION LENDING AGENCY
(r wr I hereby affirm that them Is construction tending agency,for the performshoua
tYi.�. du wort fee which Nis permit It loom(sec.3097,Civ.C.)
�W Q lender's Nldne
=z funders Address
U O I certify dust 1 have red Won application and suer the the Now information is .
IL F correct.l agree u comply with all city and cowry on inasces and stale laws relating to
.OWilding conmuction,and hereby anme
demine reprnuum ofthe m city cons the upon
�1 U above-mentioned property for inspection purymes
F a (We)agree to nae.Indemnify and kap homeless lk City of Cupertino agdmt
rte IiaNlitin.jdgmcnu.cuts and expenseswhich may in any my secure againeurt id City
U sZ in comrguence of the granting of this permit
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date ell
S� GUI.ATIONS. 9/�JOB
""l Re-roofs
s( ter Appli aHAZARDOU mate j
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wading anl.uom m ram handle bardomaterial
firethe d by Cupertim Municipal Code.e.Chapter 9.1;and the Fkalth and Salny,
smuear 25532(a)7
C]year We All roofs shall be inspected prior to any roofing material being installed.
Will the app poem or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit huardou err contaminants u defined by the Bay Arta Nr Quality Management all new materials for inspection.
District?
E)Yes `®No
I hew mad the huamme,hu crists requWments undcrChapeor 6.95 oftha Califm-
nis Hulthh S9CyC0dC sections 2550,25533 am!25534.1 ouncread dun if the Wilding
docs not cwendy haw a rmnt du it a my responsibility an mtil"the oceupant of the,
mquirt cru witch men Wmet prioruissuance Dion Cmtifcue ofa
-- one C7fE/< , to 08 Signature of Applicant Date
rrirad agenta,n All roof coverings to be Class'Aw or better