07060159 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
«:
PERMIT NO.
BUILD{NC�Q�ES� TANTAU AVE PRESIDIC SYSTEMS INC. 07060159
1 l/J v v PERMIT ISSUE DATE
OWNER'S NAME:
G E 290 RIC1<ENBACKER CIR 06/19/2007
SANITARY NO. CONTROL NO.
,ONE: (925) 4-r6-8400
BUILDING PERMIT INFO
ARCHr ECT/ENGINEER: BLDG ELECT PLUMB MCECHH
p ZO LICENSED CONTRACTOR'S DECLARATION Job Description
W 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing REMOVAL OF OLD TREATMENT SYSTEM.
:Z m with Section 7000)of Division 3 of the Business and Professions Code,and my license is
;1 ON in full force and�Cfect a,�)j
v�Z License ql; 1� LContractor
ic.# _4A3 y tq
Date (r` RCtIITE rs DECLARp ION
I ode< 1 understand my plans shall be used as public records
>yU
U.H Licensed Professional
y
OWNER-BUILDER DECLARATION
> I hereby affirm that 1 am exempt from the Contractor's License Law for the
3 p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
"y prior to its issuance,also requires the applicant for such permit to file a signed statement t;q.Ft.Floor Area Valuation
?t that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $50000
t=- (commencing with Section 70(x)of Division 3 of the Business and Professions Code)or
6 0 that he is exempt therefrom and the basis for the alleged exemption.Any violation of Number Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of 3160902 j
not more than five hundred dollars($500).
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Conti-actor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon.and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑1 am exempt under Sec B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 hsve and will maintain a Certificate of Consent to self-insure for Workees Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performanc of the
work for which this permit is issued.
❑I have and will maintain Workers.Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are: p _
Carrier. Policy No.:\h,V S. t�, `
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars(S 100)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
tom. I hereby affirm that there is a construction lending agency for the performance of
(�> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lenders Name
z Lender's Address
U C) I certify that I have read this application and state that the above information is
v. r--r correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
ahovc-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
Fr to liabilities,judgmcns,costs and xpenses which Ty i anyway accrue against said City J �,
U z in consequence of the g 'ng f th permi Date G
►- APPLICANT UNDERST ND AI fD I M LY WITH ALL NON-POINT Issued by
SOURCE REGULAp01,IS. /
a Re-roofs
Signature of Applicant/Con for Date T Of Roof
US MATERIALS DISCLOS E Type
Will the applicant or Cu ure building occupant store mile hazardous material
as defined by the Cupertino unrcrp 1 Code.Chapter 9. ,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes VO If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or forum ilding occupa t use equipment or devices which
emit hazardous air contaminants defined by the Bay Arca Air Quality Management all new r iaterials for inspection:
District?
C]Yes No
I have mad hazardtxs materi s ircmens under Chapter 6.95 of the Califor-
niaHeal Safc ode,Secti 50 2 and 255 dcrstand that ifthe building
d no cu nti h vc an tit' m ility to n 7y the occupant of the 11 Date
rcqu n whit be et r to i u f a Certificate o Occupancy. $Ignaturt'of Applicant
All roof coverings to be Class"B"or better
Owne or aut orized agent Datc